A Full Spectrum Day Spa!
Thank you for your interest in becoming a client of Sunrise Spa. This form is used to collect information about new clients and for internal purposes only. The information you supply is confidential and will be treated accordingly.
List any major surgeries, injuries, illnesses, or hospitalizations that you have had:
*Do you currently have any of the following conditions?
a) Accurate Information: I certify that the information provided on this form is accurate, complete, and up to date to the best of my knowledge. b) Release of Medical Information: Sunrise Spa shall ensure all health information remains confidential, as required by HIPAA, and will not release any of my health information without my consent. c) Consent for Treatment: I grant Sunrise Spa permission to use the health information provided for the purpose of evaluating and adjusting my treatments. d) Consent to Communication: I consent to receiving communications from Sunrise Spa regarding appointment reminders and other necessary appointment related information via phone or email. e) Acknowledgment: By signing below, I hereby acknowledge, agree, and authorize all of the above.