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Please use the COVID-19 self screening tool 24 hrs prior to your service: https://sharedhealthmb.ca/covid19/screening-tool/
If you have no COVID-19 symptoms, please continue with this Pre-Treatment Release Form.

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SKIN CARE THERAPY, HAND AND FOOT CARE (please check conditions that apply)
Do you have:
Are you currently:
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MASSAGE THERAPY AND HAMAM (please check conditions that apply)
Arthritis
Asthma
Cold Hands/Feet
Epilepsy
Headaches
Cancer
Herpes
High/Low Blood Pressure
Kidney Problems
Muscle/Neck Pain
Osteoporosis
Skin Disorders
Thrombosis
Varicose Veins
Bruise Easily
Injury
Back Problems
Circulatory Problems
Diabetes
Gastrointestinal Problems
Pacemaker
Hepatitis
HIV
Joint Pain
Liver Problems
Metal Pins/Plates
Multiple Sclerosis
Surgery
Respiratory Conditions
Spinal Disc Injury
Thyroid Problems
Pregnant
Other
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I confirm that to the best of my knowledge, the answers I have given are correct, and I have not withheld any relevant information.

By submitting this form I hereby release Ten Spa, its affiliates, officers, directors, agents and employees and the owners of Ten Spa and/or The Fort Garry from any and all claims, actions, cost, expenses, and/or damages, including attorney’s fees that I might have now or in the future for any injuries or damage arising or of in any manner resulting from the use of all spa facilities and services while in the Ten Spa and The Fort Garry, Winnipeg, Manitoba.

Such release is to be bidding upon my heirs, successors and assigns. I am fully knowledgeable as to the use of the equipment and facilities as well as my own physical limitations, while using any spa facility, and I agree to use such equipment at my own risk, without supervision. I am fully aware of that individuals with heart ailments, high blood pressure, pregnant women or anyone sensitive to heat are not advised to us the equipment or heated facilities.

By submitting this form, I authorize the collection, use and disclosure of personal information, as defined in the Personal Health Information Act (PHIA), required for treatment and/or any related administrative purpose. I understand that all my personal information is confidential, and must be treated in accordance with PHIA.

NOTE: To receive the full benefit from our treatments, jewelry must be removed prior to entering the treatment room. Please do not leave valuable items unattended. Ten Spa is not responsible for lost or stolen items.