nitalakelodgeresponsive

Client Intake Form

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Select multiple items by holding CTRL or tapping on the box.
Select multiple items by holding CTRL or tapping on the box.
Select multiple items by holding CTRL or tapping on the box.
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I acknowledge and understand that there are risks associated with services provided by The Spa at Nita Lake Lodge. Examples may include but are not limited to; bruising, aching, discomfort, short term aggravation of symptoms, and skin irritation. I acknowledge that my participation in these treatments is entirely voluntary.

I agree to discuss my concerns about possible risks with my therapist before the treatment and immediately advise them if I become uncomfortable in any way during my treatment.

I acknowledge and understand that it is important for the therapist to know my relevant medical history and that I have disclosed all known medical conditions, including any mental or emotional conditions for which I have received treatment within the last 12 months.

I will disclose any new condition that may develop after my completion of this form. The information disclosed by me is true and complete to the best of my knowledge.

I authorize copies of any patient record created at the Spa at Nita Lake Lodge to be shared with all registered professionals who work at The Spa at Nita Lake Lodge who may provide me with treatment.

I understand this will enable The Spa to maintain a complete patient record on my behalf. I understand that I may revoke this permission in writing at any time in the future.

I acknowledge inappropriate conduct of any nature will not be tolerated and may result in the treatment being terminated. 

I assume all risks involved in my participation in the services provided by The Spa, its employees and spa therapy practitioners. I agree to release and forever discharge The Spa at Nita Lake Lodge, its owners, its directors, employees and contractors from any claims, losses, damages, actions or causes of action arising out of any loss, injury, damage to my person or property arising from my involvement with the services provided by The Spa at Nita Lake Lodge. 

The contents of this form and my patient records will be kept confidential unless I have expressly or impliedly consented to the release of my information or, where there is a legal requirement to provide my information to a third party.

I acknowledge and confirm that no guarantee or assurance of treatment results have been made to me regarding my services provided by The Spa at Nita Lake Lodge.

I acknowledge that I am over the age of 19, have read this Waiver, understand it and I agree to be bound by this Release and Indemnity.

*if I do not understand and therefore am not capable of providing consent, or under the age of 19, this consent is instead provided by an individual who is authorized and able to make health care decisions on my behalf (parent or legal guardian).


Reach us by email: spa@nitalakelodge.com
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604 966 5700