Please complete all sections as fully as possible.
All information is held in strict confidence and used solely for treatment purposes.
Personal Details
About Your Visit
Stress Level
Treatment History
Skin Type — For Facials Only
Please tick all that apply to your skin type.
Session Goal
Health Check — Please tick all that apply
Declaration
BY SUBMITTING THIS FORM, you agree to the following:
- I give my permission to receive massage, facials or waxing services.
- I understand that therapeutic massage is not a substitute for traditional medical treatment or medications.
- I understand that the therapist or aesthetician does not diagnose illnesses or injuries, or prescribe medications.
- I have clearance from my physician to receive facials and massage therapy.
- I understand the risks associated with massage therapy, facials, and waxing include, but are not limited to:
- Superficial bruising or redness
- Short-term muscle soreness
- Exacerbation of undiscovered injury
I, therefore, release Marion Jenkins Therapies and the individual therapist or aesthetician from all liability concerning these injuries that may occur during the massage session.
- I understand the importance of informing the therapist of all medical conditions and medications I am taking, and the massage therapist knows about any changes to these. I understand that there may be additional risks based on my physical condition.
- I understand that it is my responsibility to inform the therapist or aesthetician of any discomfort I may feel during the session so he/she may adjust accordingly.
- I understand that the therapist may terminate the session at any time.
- I have been given a chance to ask questions about the session and my questions have been answered.
Signature
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Consent & Marketing
