Head Spa Client Forms

Japanese Head Spa Client Consent Form

1) I give my permission to receive a head spa treatment.

2) I understand that this treatment is not a substitute for traditional medical treatment or medications, and is not a medical procedure to cure eczema, psoriasis, or any skin disease.

3) I understand that the provider does not diagnose illnesses or injuries or prescribe medications.

4) I understand that this treatment is for relaxation only.

5) I acknowledge that if I have any medical conditions, pregnancy, allergies, medications (oral or topical) that may be affected by the treatment or services requested, I have the opportunity to discuss such conditions with the service provider. I also have clearance from my physician to receive this treatment.

6) I understand the risks associated with this treatment include, but are not limited to:

• Superficial bruising

• Short-term muscle soreness

• Exacerbation of undiscovered injury

I therefore release the company and the individual provider from all liability concerning these injuries that may occur during the head spa session.

7) The company and provider are not responsible for any allergic reaction I experience.

8) I understand the importance of informing my provider of all medical conditions and medications I am taking, and to let the provider know about any changes to these. I understand that there may be additional risks based on my physical condition.

9) I understand that it is my responsibility to inform my provider of any discomfort I may feel during the session so he/she may adjust accordingly

10) I understand that I or the provider may terminate the session at any time.

11) I have been given a chance to ask questions about the session and my questions have been answered.

By signing below, you attest that you have provided accurate and current information on this form and answered all medical and health-related questions truthfully and completely. Your signature also certifies that you understand that BBronzed Mobile Tanning reserves the right to deny service to any client due to a health condition he or she has that may pose a potential risk to practitioners or other clients, including those that pose a risk of potential contamination to service areas. Furthermore, signing below verifies that you understand that you are responsible for informing BBronzed Mobile Tanning and/or its employees of ANY and ALL changes to your health condition as regards any question on this form or any potential public health risk that may arise from any change in your health condition. You acknowledge and accept that withholding information or providing misinformation may result in contraindications and/or irritation to the hair and scalp from treatments received. The treatments you receive here are voluntary and you release BBronzed Mobile Tanning from liability and you assume full responsibility thereof.

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