CustomerSurveyEng Prefix Mr Mrs MsFirst NameLast NameBirth DateMobile NumberEmailPreviousNext1. Guest History. Please indicate which of the following applies to you. This Information will assist us in achieving the best results for your treatment. Arthritis Wears contact lenses Recent Injury/Illness Cancer High/Low Blood Pressure Skin condition/Irritation Thyroid condition Heart Disease/Surgery Claustrophobia Hemophilia Frequent Headaches/Migraines Joint pain/problems Back/Neck Pain Bursitis Diabetes/loss of sensation All above NonePreviousNext2. Have you experienced any of the following symptoms: fever, cough, new loss, of taste or smell, muscle or bodyaches, shortness of breath, fatigue, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea that began in the last 72 hours? Yes NoPreviousNext3. Have you tested positive for COVID-19 in the last 14 days, or are you awaiting test results? Yes NoPreviousNext4. Have you been in close contact with someone who has tested positive for COVID-19 in the last 14 days, or someone who is awaiting test results? Yes NoPreviousNext5. Massage is contraindicated (should not be done) where certain medical condition exist. Please indicate if you have any of the below or other conditions that may be relevant to your massage. Tissue swelling Acute disease accompanied by fever Acute inflamantory process (client with bursitis may be treated) Acute skin conditions such as eczema, seborrhea and psoriasis, which may be treated without oil Known thrombosis (blood clots) Gastric or duodenal ulcers Prominent hernia; gastric or duodenal ulcer None of the above All above OtherPreviousNext6. If other, please specify:PreviousNext7. Are there any sensitivities or allergies that we should know that might affect your treatment? Yes NoPreviousNext8. Have you had any surgery or plastic surgery within the past year? Yes NoPreviousNext9. Are you currently pregnant? Yes NoPreviousNext10. Is this your first professional massage/body treatment? Yes NoPreviousNext11. For massage only, what type of pressure do you prefer? Light Moderate Deep N/APreviousNext12. Is there anything else we should know that might affect your treatment? You may experience some symptoms as a result of massage/body treatments such as muscle stifness and/or soreness, slight headache, nausea, and possible isolated discoloration of the skin. Guest must be 12 years or older to receive massage/body treatments. Parental Wavier of Liability must be completed for guests 12-17 years of age. Yes NoPreviousNext13. I understand that if I am currently taking any medication, it is my responsibility to confirm with my doctor that is not contraindicated by the spa treatments I am about to receive Yes NoPreviousNext14. I agree that my health questionnaire will be kept on file according to local laws Yes NoPreviousNext 15. Please read this document carefully as it affects your legal rights. I, the undersigned, represent and warrant that I am at least 18 years old and, if I am signing this waiver and release on behalf of someone under the age of 18 (a "Minor"), that I am the legal guardian of the Minor(s), whose name(s) is/are listed below. I also acknowledge, agree, represent and warrants as to the following, on my own behalf and on behalf of any such Minors: I want to receive or participate in massages, facials, other body treatments and related services, at the LaTox Indonesia (the "LaTox") (together, the "Treatments") or to use certain facilities available at the LaTox, including saunas and relaxation rooms (all such facilities, the "Facilities") (the Treatments and Facilities, together, the "Activities"), including those for which I have booked appointments at LaTox, that are indicated on my Guest Health Questionnare (the"Questionnare") or other registration form on file with the LaTox. I ACKNOWLEDGE THAT NO REPRESENTATION AND WARRANTIES HAVE BEEN MADE TO ME BY ANY OF THE LATOX PARTIES (as defined below) CONCERNING THE QUALITY, FITNESS, DISINFECTION AND/OR CONDITION OF THE FACILITIES, THE PERSONNEL DELIVERING SERVICES OR THE SAFETY OF THE ACTIVITIES. I agree to abide by all LaTox Indonesia rules, procedures and regulations relating to my participation in the Activities, which may include social distancing requirements or the requirement to wear a mask during my participation. In consideration of the LaTox permitting me to receive or participate in the Activities, I hereby waive and forever relinquish any and all rights and any claims, losses, causes of action, damages, liabilities, costs and expenses (together, "Claims") which I may now or in the future have against the LaTox Indonesia, and each such entity's parent, subsidiary and affiliated companies, successors and assigns, and each of the foregoing entities' officers, directors, employees, members, contractors and agents (together, the "LaTox Parties"), in connection with my use or receipt of, or my participation in, the Activities. This waiver and release extends to all such Claims whether foreseeable or unforeseeable and whether known or unknown to me at the time I sign this document. I specifically acknowledge that this waiver and release extends to Claims or portions of Claims that may be caused by one or more LaTox Parties' ordinary negligence; I will indemnify and hold harmless the LaTox Parties from any and all Claims of whatsoever nature and by will never brought arising out of or in connection with my use, operation, possession or participation of the equipment or in the Activities, as applicable; Finally, I understand and agree that the above terms are contractual and not mere recitation. I accept I don't acceptPreviousNext16. Guest Using Receiving or Participating in Activities is at Least 18 Years Old? Yes NoPreviousNext17. For a memorable and mindful experience, kindly indicate if you would like to add one enchancement of the following to your treatment.* Russian Upper Detox Signature Detox Full Detox Maternity Detox All Above Prev Done