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Client Intake Form

Medical History
Please check all that apply:
Are you currently taking any medications?
Do you have any allergies?
Have you had any surgery in the last 5 years?
Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, or hormonal pellets?
Do you use recreational drugs?
Service Information
Liability Waiver

I confirm that I am of legal age to receive treatment from MOI aging gracefully and that I am requesting and consenting to receive treatment of my own free will, without duress. I confirm that I have been told how the equipment works, given the opportunity to inspect the equipment, learned about the MOI aging gracefully program, and have had any questions that I may have answered. I confirm that have disclosed any and all medical conditions and have consulted a physician if required to receive approval for treatment.

I understand that if at any time during my treatment, I experience any pain or discomfort, I will notify the technician immediately so that the treatment can be adjusted to suit my comfort level. At any time if I wish to stop treatment I will let the technician know.

I confirm that I have advised the MOI aging gracefully technician of all known medical conditions, surgeries, allergies, and injuries. I will continue to keep MOI again gracefully informed of any medical issues or changes in my physical condition which may affect services that I have scheduled in MOI again gracefully. I acknowledge that neither MOI aging gracefully, nor its employees are engaged in diagnosing or treating medical diseases or conditions. I acknowledge and assume all the risks associated with any service offered by MOI aging gracefully, including but not limited to exposure to COVID 19. I will not hold MOI aging gracefully or its employees liable due to any injury or illness (present or future) resulting from or relating to my treatment or attendance at the facility.

MOI aging gracefully, will not tolerate any inappropriate acts, I understand that my session will be terminated due to any form of inappropriate behaviour. We are committed to professionalism and expect the same from our clients. 

I have read and fully understand this agreement and all information detailed above. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages that might occur to me while I am undergoing this procedure. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today. 

Media Consent

I, hereby grant MOl aging gracefully the right and permission to use and publish photographs, videos, and/or other media featuring me in promotional and advertising materials, including but not limited to social media channels, websites, and print materials. I understand that this media may be used to showcase the services and products offered by MOl aging gracefully.

I understand that MOl aging gracefully will ensure that my privacy is maintained and that any sensitive or identifying information, including my name, contact details, private areas, or tattoos, will be removed or obscured before the media is published.

I release and discharge MOI aging gracefully and its agents and employees from any claims, demands, or causes of action arising out of or in connection with the use of this media.

This release constitutes the sole, complete, and exclusive agreement between myself and MOl aging gracefully with respect to the use of any media featuring me. I acknowledge that I have read and understand this release and I voluntarily sign it.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages which might occur to me while I am undergoing this procedure. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

By signing below, I agree to the following:

I have completed this form to the best of my ability and knowledge, I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment suitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the spa for any injury or damages incurred due to any misrepresentation of my health.

Thank you!

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