ESSpa Program Consent Form
esSpa Organic Hungarian Skincare and eDryBar Salon
Client Information
Name
*
First Name
Last Name
Age
*
Date of Birth
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
This section is required for any Guest under 18 years old. Thank you.
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Please answer the following questions and rate a scale of 1 (minor) to 3 (severe) the following:.
I willingly allow ESSPA to perform the treatment or service requested. I understand that it is up to me to inform my therapist - verbally and below - of any issues that might be of concern.
I willingly allow the application of lotion(s), oil(s), and ointments (including CBD/HEMP based products if requested) to my body. If I have any allergies or other issues, I understand that it is my responsibility to inform my therapist - verbally and herein.
I am NOT currently using any retinol products such as Accutane, Retin-A, Tretoin, etc. I have NOT used any retinol products (Retin-A, Accutane, etc.) in the past 2 weeks.
I have NOT used any retinol products (Retin-A, Accutane, etc.) in the past 2 weeks.
Have you Heard about CBD (Cannabidiol?)
Yes
No
If Yes, Have you ever used CBD products or services before?
Yes
No
Do you object to today's service using products that might contain CBD/Hemp.
Yes
No
Severity of Issues
Please answer the following questions and rate a scale of 1 (minor) to 3 (severe) the following:.
Constipation/Diarrhea
Stomach Pain/Discomfort
Joint Pain
Insomnia
Energy Loss
Eczema / Skin Issues
Food Allergies
Airborne Allergies
Asthma / COPD
Use of OTC Pain Meds (Tylenol, Asprin, etc)
Frequent Antiboitic use
Alcohol Intolerance
Migraine Headaches
Irritability/Frustration
Socially Discouraged
Nausea
Sinus Congestion
Easily Distracted
Memory Loss
Total of above Ratings =
Brain Based Cravings
Please answer the following questions and rate a scale of 1 (minor) to 10 (severe) the following:.
Hunger
Cravings (of anything)
Satiation
Water Intake
Night Grazing
Health Data
We ask the following questions ONLY to ensure that you receive the best possible level of service during your visit. Please type NONE in the appropriate box below if applicable. Thank you.
Do you have any allergies? (fruits, bees, nuts, shellfish, latex, etc.)
*
If yes, please specify on the field above.
Are you currently taking any prescription or OTC medications?
*
If yes, please specify on the field above.
Are you pregnant? (Female only. If yes, please state how many months.)
*
If yes, please specify on the field above.
Have you been recently hospitalized? (If yes, please describe. If no, type no.)
*
If yes, please specify on the field above.
Do you have any current injuries, soreness or pain? (If yes, please describe. If no, type no.)
*
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Thyroid, Kidney problems, epilepsy, scoliosis, communicable disease, etc.? (If none, please type None.)
*
If yes, please specify on the field above.
Do you have High Blood Pressure?
*
YES
NO
Have you had Cancer (treatments or issues) in the past 12 months?
*
YES
NO
Do you have any kind of Liver Disease (including Hepatitis and/or Cirrosis)
*
YES
NO
Do you have any open wounds or bruises?
*
YES
NO
Do you have a Pacemaker or other implant device?
*
YES
NO
Do you have HIV/AIDS?
*
YES
NO
What Service(s) are you having Today?
Please be as specific as possible
Date of Last Similar Treatment
What result(s) are you expecting?
Have you tried other methods to accomplish this goal? If so, what and when? What were the results?
*
If yes, please specify on the field above.
How long have you been trying to accomplish the goal you have set today?
*
If yes, please specify on the field above.
What is standing in the way of keeping you from reaching your goal(s)?
*
If yes, please specify on the field above.
Consent and Waiver
Type a question
*
I willingly allow ESSPA to perform the treatment or service requested. I understand that it is up to me to inform my therapist - verbally and below - of any issues that might be of concern.
I authorize ESSPA to charge me for the treatment(s) or service(s) requested.
I understand that I am visiting ESSPA for a voluntary, non-medical, alternative treatment and if I have any medical concerns, I will talk to my medical provider for approval.
I am NOT currently using any retinol products such as Accutane, Retin-A, Tretoin, etc. I have NOT used any retinol products (Retin-A, Accutane, etc.) in the past 2 weeks.
I do NOT have a pacemaker or any other implant medical device.
I do NOT experience seizures, nor do I have epilepsy or any other ailment that might stop me from receiving services at ESSpa, including (but not limited to) LED (Red, Blue, Infared) Light Therapy.
I do NOT currently have a Thyroid or any other medical condition that might limit my ability to participate in any ESSpa Weight Loss, Gut or Pain Relief Program(s) - including supplements, services or other services administered by and/or at ESSpa.
I will immediately contact an ESSpa representative should I experience any unknown reaction to any ESSpa services and/or products.
I release ESSPA Inc., its owners and my therapist for liability or responsibility in case of any accidental illness, or injury.
I agree to pay for my service(s) at the time such service(s) is/are rendered.
I acknowledge that all information I provided in this form is true and accurate.
Signature of the Client
*
Date Signed
-
Month
-
Day
Year
Date
Submit
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