Consent and waiver
CONSENT AND WAIVER FORM
Your Age * |
Select Your Treatments (Choose all that apply) * |
Do you have any skin problems pertaining to your face or body?
Do you have metal implants, a pacemaker or body piercing?
Please rate your current stress levels 1 =low stress, 4=high [1-4]
I accept that any treatment I have taken is at my own risk. I certify that i have read and completed the
above to the best of my knowledge. I understand that failure to disclose information requested above may
result in adverse side effect, unknown because of this to which I accept full liability/responsibility.
I fully understand the above consent/permit and treatment/s to be carried out. The undertaken of the treatment/s has been fully explained to me. I accept full responsibility for this and or other complications which may arise or result during or following any procedure that is performed at my request.
I accept that if I am not satisfied with the treatment I must inform the therapist and/or request to speak to the manager immediately following the treatment.
I fully understand the above consent/permit and treatment/s to be carried out. The undertaken of the treatment/s has been fully explained to me. I accept full responsibility for this and or other complications which may arise or result during or following any procedure that is performed at my request.
I accept that if I am not satisfied with the treatment I must inform the therapist and/or request to speak to the manager immediately following the treatment.
| Customer's Name: | Patch Test Date: | |
| Customer's Signature: | ||
| Date received treatment: |
