Client Questionnaire & Waiver

At Realfine Wellness Spa, we uphold the right to refuse service to any client in cases where their behavior is disrespectful, aggressive, inappropriate, or poses a threat to the safety and comfort of our staff and other patrons. We prioritize creating a safe, welcoming, and professional environment for all individuals seeking relaxation and wellness. Any conduct that undermines this atmosphere may result in the refusal of service. We appreciate your understanding and cooperation in maintaining a positive experience for everyone at our spa.

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Your time is valuable, and so is ours. We kindly request that you submit genuine and serious inquiries. This helps us ensure prompt and efficient service for all our clients. Thank you for your understanding and cooperation.

Name *

Enter Full Name Please

Contact Phone Number *

Contact Email *

Please Select Location *Las Vegas, NV (11135 S. Eastern Ave SUITE 150 Henderson, NV 89052)Home Care Therapy (Exclusive to San Diego County))

Service(s) Interested *

• Brazilian Lymphatic Drainage Massage

Lymphatic Massage Service Tier Request *

• Platinum “Pamper Me Please” Treatment – $199 (Full Body + Full Arms + Full Face) + $25 Travel Fee — Serviced by Chachi

**Discounted $200 OFF (6) Package Available Upon Request**

Lymphatic Massage Service Tier Request *

• Bronze “Better Me” Treatment – $155 (Full Body)
• Gold “Gotta Have It” Treatment – $175 (Full Body + Full Arms)
• Platinum “Pamper Me” Treatment – $199 (Full Body + Full Arms + Full Face)

Not Accepting New Clients after January 25, 2026

Home Care Therapy Treatment

*** Exclusive to San Diego County Clients *** (Limited Availability)

Please specify type of Location: *

• House
• Townhome/Apartment
• Business (Private Office)

Address *

Address Line 1

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Preferred Date of Service *

Preferred Appointment Service Time(s) *

• 12:00pm – 3:00pm (Afternoon)
• 3:00pm – 5:00pm (Late Afternoon)
• 5:00pm – 7:00pm (Evening)

Please specify all of the following:

Parking Available *

• Yes
• No

Accessibility (check all that apply) *

• Gated Community
• Stairs
• Elevator
• Dogs, Cats, or Other Pets
• N/A

Preferred Appointment Service Time(s) *

• 11:00am – 1:00pm (Morning)
• 1:00pm – 3:00pm (Afternoon)
• 3:00pm – 6:00pm (Late Afternoon)

Have you had any surgeries in the past? *

• Yes
• No

Please list all past surgeries, including cosmetic or elective procedures (e.g., breast augmentation, liposuction, etc.): *

Please Indicate Your Health Condition(s) *

• Low Energy
• Recovery for Athletic/Bodybuilding Performances
• Lymphedema
• Lipedema
• Bad PMS
• Post Partum
• Chronic Joint/Bodily Pain
• Thyroid Condition
• Prenatal Care
• Menopause
• PCOS
• Hysterectomy
• Migraines
• Endometriosis
• Leaky Gut
• Gut Health Issues
• Digestive Issues
• Slow Metabolism (Difficulty Dropping Weight)
• Cancers of Any Form
• Overall Excess Bodily Inflammation
• Other (Please Specify)

Other (Please Specify) *

Known Allergens and or Allergic Reactions to Specific Products *

• None
• Yes (Please List details in next step)

List any known Allergens, and or Allergic Reactions to Specific Products *

Additional Information *

Age *

Approx. Height *

Approx. Weight *

Realfine Wellness Spa utilizes a cashless payment system via VENMO or ZELLE. All Other Credit Cards, Apple Pay, Google Pay are not accepted forms of payment *

• I am registered with VENMO and/or ZELLE, and I understand Realfine Wellness Spa Only accepts VENMO or ZELLE payments.
• I am not Registered with VENMO and/or ZELLE, and I need to register please.

* No charges associated with this request at the moment.

Please Download VENMO or ZELLE on your Phone Device and register for a Free Account *

• I have registered with VENMO and/or ZELLE, and I understand Realfine Wellness Spa Only accepts VENMO or ZELLE payments.

* No charges associated with this request at the moment.

Liability Waiver *

• I Hereby Affirm That I Have Read And Fully Understand The Below Statements. I understand that the massage treatment(s) that I receive is/are provided for the purpose of relaxation, relief of stress, muscular tension, pain, and to aid the body with its natural healing process. A massage therapist works soft tissue and may integrate gentle range of motion exercises to the joints but will not administer spinal manipulations. If I experience any pain or discomfort during the treatment I will immediately inform the therapist so that she can adjust her techniques and pressure to within my level of comfort. I am also informed that I have the right to stop massage treatment at any time. I further understand that massage is not a substitute for medical examinations or diagnosis and so I should seek a physician or other health professional should I need aid with mental if physical ailments. I agree that all of the information that I have provided in my health history form is accurate. I acknowledge that to ensure appropriate treatment it is of upmost importance to inform my massage therapist of any old, current, or new injuries as well as inform them of any changes in my health status, or and concerns I may have. I am aware that on rare occasion massage therapy may cause delayed onset muscle soreness. If it should happen it should go away within 48-72 hours. Although most Clients do not bruise from wood therapy, slight bruising may occur. Bruising can be caused due to excessive inflammation in certain areas that your body may carry, and/or low iron. It is very important to stay hydrated at all times. I have been informed that the massage therapist has to meet standards and principals enforced by the Massage Therapy Act & Regulated Health Professionals Act and may at any time refer a client elsewhere if she feels that her client would benefit from alternatives to massage therapy or have greater potential of succeeding health wise with an alternative practitioner. The Client hereby confirms that they have disclosed all known allergens and any allergic reactions to specific products and oils. Lastly, I have been informed and/or I am aware of the method of payment is VENMO or ZELLE ONLY, the fee of the massage therapy treatment as well as all spa policies. If you understand everything above and give consent for treatment please sign and date below.

Signature *

Clear Signature

Date *

Your time is valuable, and so is ours. We kindly request that you only hit submit if your inquiry is genuine and serious. This helps us ensure prompt and efficient service for all our clients. Thank you for your understanding and cooperation. *

• My Inquiry is Genuine and Serious

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