Have you ever experienced any of the following conditions? 

• Cancer
• Diabetes
• Hysterectomy
• AIDS/HIV
• Psoriasis
• Spinal Injury
• Keloid Scarring
• Menopause, 
• High/Low Blood Pressure
• Claustrophobia,
• Hormone Imbalance
• Hepatitis A/B/C
• Rosacea
• Cold Sores
• Blood Clot Disorder
• Circulation Disorder
• Metal Implants
• Pins/Heart Disease
• Epilepsy/Seizures
• Migraines/Headaches
• Eczema
• Immune Disorder 
• Skin Disease/Disorder
• Varicose Veins/Phlebitis
• Pacemaker/Defibrillator
• Thyroid Disorder
• Blush/Redden Easily
• Depression/Anxiety
• Bruise Easily
• Lupus or Fibromyalgia  

Client Consent: I understand, have read and completed the questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the practitioner of my current medical or health conditions and to update this history. I understand that the services offered are not a substitute for medical care and any information provided by the practitioner is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the practitioner in giving better service and is completely confidential.

The treatments I receive here are voluntary and I release Sacred Healing Spa and Crystal Owens from any liability and assume full responsibility thereof.

General Medical Aesthetics Release Form / Hold Harmless

 

I hereby consent to and authorize Sacred Healing Spa to perform any of the following treatment: Lipo Cavitation, Skin Tightening, RF Facial, Wood Therapy, Vacuum Butt Lift Therapy, Accupresure Massage, Lymphatic Massage, Teeth Whitening, Teeth Gems or Sauna Detox.

Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize that there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the practitioner immediately. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. Ihave read and fully understand this agreement and all information detailed above. I understand the treatment and accept the risks. All my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the technician (nor the establishment), whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. I also release Sacred Healing Spa of any liability that may arise from this procedure.

Ultrasonic Lipo Cavitation Waiver 

Upon execution of this form I assume all risk of loss, liability. damage or costs, including bodily injury or property damage that may incur arising out or in connection to this procedure, to my acts and/or omissions. I fully understand the terms set forth in this form, and I hereby waive my rights freely and voluntarily without any inducement, assurance, or guarantee being made to me to the fullest extent allowed by law.