New Client Treatment Waiver Form

Serendía Wellness, Jessica Barker

Kingcup Drive, Bisley, Surrey GU24 9HH

Phone: 07707 816 606

Email: Jessica@Serendiawellness.com

Name

First NameLast Name

Email

example@example.com

Date of Birth

Date

Phone Number

Address

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code

MEDICAL DECLARATION: Are you currently experiencing any of the following?

Skin Specific (For facial treatments)

Please give further detail here regarding medical info if required

Do you have any allergies to any ingredients including essential oils/botanicals?

Are you currently taking any medications / supplements? Please give detail.

In order to get to know what you require from the treatments, please let me know any specific wellness/skin goals?

Please detail anything relevant to your treatment.

Marketing: Where did you hear about Serendía Wellness ?

If word of mouth, please let me know who.

General Data Protection Guidelines: 'I' The Client, consent to 'Serendía Wellness' using my contact details to give me information and updates about any offerings. I understand that my personal details will be kept as securely as possible and never be passed to a third party.

Disclaimer (Please Read Carefully)

The treatments and services received or utilized at Serendía Wellness are intended for general wellbeing purposes only and are not intended to be a substitute for professional medical treatment or diagnostic. You, 'The Client' will fully indemnify and hold harmless from and against all liabilities, claims arising out of or in connection with the treatments and services undertaken.

I recognise that it is my responsibility to notify my 'Therapist' of any serious illness or medical condition before the commmencement of treatment and to provide correct knowledge to enhance the treatment. 'I' will also inform my ‘Therapist’ of any future changes to medical conditions or lifestyle changes which arise, including Pregnancy. (For persons under the age of 18, parental consent on behalf of the minor is required. )

I have been open and honest regarding the above and would like to commence having treatment.

Signature

Date

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