Intake Form.
New Client Agreement. &
Payment Authorization.

THIS IS A ONE-TIME FORM

THIS IS A LEGAL DOCUMENT AND BINDING AGREEMENT BETWEEN THE PARTIES. CLIENT AGREES TO CAREFULLY AND COMPLETELY READ AND COMPLY WITH THIS AGREEMENT. THIS AGREEMENT CONTAINS CERTAIN CONDITIONS AND RESTRICTIONS ON THE USE OF THE SERVICES, MEMBERSHIP, CLIENT RIGHTS, AND LEGAL PROTECTIONS. YOU SHOULD NOT SIGN THIS AGREEMENT WITHOUT READING AND UNDERSTANDING ITS CONTENTS.

THE AGREEMENT COVERS ALL SERVICES AND WILL CONTINUE AND/OR BE AMENDED FROM TIME-TO-TIME, UNTIL CLIENT CANCELS THIS AGREEMENT.

HolistiqueByDesign.com

info@holistiquebydesign.com

(719) 204-4736

Holistique LLC, a Colorado limited liability company is independently operated and owns this Agreement.

Holistique LLC is not for emergency consultations/services, in an emergency, call 911.

This Client Agreement governs the relationship between Holistique LLC, a Colorado limited liability company (“Holistique” or “We”), and Client, Holistique’s provision of Services to Client, and Client’s obligations and rights related to Holistique and its Providers and Staff. The Client is defined as the individual who signs this Agreement and receives services from Holistique. The Client may also be referred to herein as “You” or “Your.” While You may not receive all available services, this Agreement confirms your consent and understanding of all available services and Holistique’s provision of those services.

A Full Copy Of This Agreement Is Available To Download Here.

Today's date

Client/Guest Information

Status

I am the Client

I am a Guest of a Client

Who are you a guest of?

if you are a not a guest, and selected "I am the Client" write "NA" in the text field.

First name

Last name

Address

*The email you provide will be used to send important updates about your services, including scheduling details, staff changes, and special promotions. We respect your inbox and do not send spam—just relevant updates to help you stay informed.

Phone

Birthday

Month

Day

Year

Select Age Type

Emergency Contact Information

In the event of an emergency, please contact the following person:

*If Client is a minor, the Emergency Contact MUST be the legal guardian.

First and Last Name

Relationship

Phone

Email (Optional)

Section 1 General Agreement Terms

Review Section 1 Here.

Client Acknowledgement Section 1

I have accessed, read in completion, understand and AGREE to Section 1 General Agreement Terms

I have accessed, read in completion, understand and DO NOT AGREE to Section 1 General Agreement Terms

Section 2 Privacy, Confidentiality, Professional Disclosure Statement

Review Section 2 Here.

Client Acknowledgement Section 2

I have accessed, read in completion, understand and AGREE to Section 2 Privacy and Confidentiality

I have accessed, read in completion, understand and DO NOT AGREE to Section 2 Privacy and Confidentiality

Client Preferences And Health History

Please answer each question with as much detail as possible so that Your Provider(s) can create a truly customized experience to compliment Your needs:

Do you have gender preferences in providers? (i.e. male or female is fine for all services, etc.)

Do you have communication preference during Services? (i.e. quiet massage, more detailed instruction, hearing impairment needs, etc.).

What are your touch preferences? (this will depend on the type of service and your personal goals, but please identify if there are any areas that require focus for massage, may be uncomfortable during training, etc.)

Indicate below any/all medical conditions. If you have "Nothing Required To Add" select that option (second to last). If your condition is not listed select "Other" (last option) and write in your condition.

Please explain all medical conditions (including, but not limited to surgeries, mental and physical health diagnosis, skin conditions, disease, etc.)

Client Goals, What You Want Your Provider to Know Up-Front, Important Information to Your Wellness Journey:

What else should we know? (let us know anything that helps us to help You.)

File upload (add any files your provider may need, documents only, limit 5)

Section 3 Guest Privileges

Review Section 3 Here.

Client Acknowledgement Section 3

I have accessed, read in completion, understand and AGREE to Section 3 Guest Privileges

I have accessed, read in completion, understand and DO NOT AGREE to Section 3 Guest Privileges

Section 4 Acknowledgement

Review Section 4 Here.

Client Acknowledgement Section 4

I have accessed, read in completion, understand and AGREE to Section 4 Acknowledgement

I have accessed, read in completion, understand and DO NOT AGREE to Section 4 Acknowledgement

Client Signature

I (Client) have read and understand this Agreement, including the waiver of liability, assumption of risk, and indemnity provisions, fully understand its terms, and understand that I am giving up my rights, including my right to sue. I acknowledge that I am signing this Agreement freely and voluntarily, and intend by my signature to be a complete and unconditional bound hereto, to the greatest extent allowed by law.

Client Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

*You may enter text by typing or by using your mouse or touchscreen to write directly in the field.

Consent for Minor

Parent/Legal Guardian Signature (*If no legal guardian is required, client will write NA.)

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

*You may enter text by typing or by using your mouse or touchscreen to write directly in the field.

Section 5 Payment Authorization

Authorization Statement:

I authorize Holistique LLC., to charge my card (as listed below) for services and/or membership provided through Holistique, LLC and/or its contracted service providers (current and future).

Guest will input “GUEST” is all text fields, filling number fields with “1” and the signature block with “Guest”

PRIMARY PAYMENT

Card Holder Name

Billing Address

Card Type (Visa, Master Card, AMXS, etc...)

Card Number

Card CVV Number

Card Expiration Date

Month

Day

Year

Legal Card Holder Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

*You may enter text by typing or by using your mouse or touchscreen to write directly in the field.

Payment Card Industry Data Security Standard

Holistique, LLC utilizes American Express Business, Vista Wix and Google Business for all billing, invoicing, payment/pay processing and related records storage. All are Payment Card Industry Data Security Standards (PCI DSS) compliant. For full information please review their compliance websites at:

Intake Form. New Client Agreement. & Payment Authorization.

THIS IS A ONE-TIME FORM

Client/Guest Information

Emergency Contact Information

Section 1 General Agreement Terms

Section 2 Privacy, Confidentiality, Professional Disclosure Statement

Client Preferences And Health History

Section 3 Guest Privileges

Section 4 Acknowledgement

Client Signature

Consent for Minor

Section 5 Payment Authorization

Holistique

Intake Form.
New Client Agreement. &
Payment Authorization.