Grail Springs Health History Questionnaire

An accurate health history is important to ensure that it is safe for you to receive treatments. We cannot book your treatments until this form is filled in and sent.
All information gathered for this treatment is confidential.

Your submission contains the following errors:
Name is a required field.
Street Address is a required field.
City is a required field.
Prov. / State is a required field.
Phone is a required field.
Invalid e-mail address.
Email is a required field.
Date of Birth is a required field.
Emergency Contact (Name, relation, phone number) is a required field.
Height is a required field.
Weight is a required field.
Robe Size is a required field.
Slipper Size is a required field.
Arrival Date and Reservation Number is a required field.
Departure Date is a required field.
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Please indicate conditions you are currently or have previously experienced







































































































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Grail Springs recommends that you have a medical exam before you visit us. If there are any medical reasons that would affect your participation in the programs, please obtain a signed release from your physician. I hereby state that I am in sound physical condition and to my knowledge there is no reason why I should not participate in the planned program at Grail Springs. I acknowledge that Spa Therapy Treatments are not a substitute for medical diagnosis or examination. It is recommended that I see a Medical Practitioner for that service. I acknowledge that I have the right to withdraw consent with regard to treatment, treatment areas, and / or techniques used at any time. I consent to receiving Spa Therapy Treatment(s).