Xpress Herbs Disclaimer for Health Preservation and Wellness Services

Xpress Herbs Disclaimer for Health Preservation and Wellness Services

颐禾堂养生保健服务免责声明
全名 Full Name*

First NameLast Name
性别 Gender *
出生日期 DOB *

MonthDayYear
Date
电子邮件 Email Address*
example@example.com
电话 Phone Number*
Please enter a valid phone number.
地址 Address

Street Address

Street Address Line 2

CityState

Zip Code
您目前的健康问题或身体不适是什么？Please describe your current health concerns or symptoms.*
Health issues or discomforts
为保障您的安全与服务效果，请注意以下情况（可多选）To ensure your safety and the effectiveness of the service, please pay attention to the following situations (multiple choices allowed):*

怀孕Pregnant/月经期 Menstrual Period/哺乳期 Breastfeeding皮肤有破损 Skin Damage / Infection发热或急性感染期间 During fever or acute infection period恶心,呕吐 Nausea or vomiting头晕 Dizziness神经性疾病（如癫痫等） Neurological disorders (e.g., epilepsy)近期手术或外伤恢复期 Recent surgery or injury recovery心脏病 Heart Diseases有放置心脏起搏器 With an implanted pacemaker高血压 High Blood Pressure严重慢性疾病（如肝肾功能不全、糖尿病并发症） Severe chronic diseases (e.g., liver/kidney dysfunction, diabetic complications)化疗中 Chemotherapy血液系统疾病（如凝血功能障碍、长期服用抗凝药物） Blood disorders (e.g., coagulation dysfunction, long-term use of anticoagulants)空腹、过饱或过度疲劳状态 Under fasting, overeating, or excessive fatigue conditions酗酒或使用违禁/非法药物后 After excessive alcohol consumption or use of prohibited/illegal substances过敏体质（对精油、草药或外用产品过敏） Allergic constitution (especially to essential oils, herbs, or topical products)精神疾病或无法有效沟通者 Mental disorders or those unable to communicate effectively未成年人（需监护人同意并陪同） Minors (require guardian’s consent and accompaniment)都没有以上情况 None Of The AboveOther
重要提示 Important Notice
若您有以上身体情况，请提前如实告知本机构及服务人员，以便评估是否适合接受本服务。
If you fall under any of the above categories, please truthfully inform our institution and service staff in advance so that we can assess whether the service is suitable for you.
未如实告知可能导致的后果，本机构及服务人员不承担任何责任。
Our institution and service staff shall not be held responsible for any consequences caused by failure to disclose relevant conditions.

所有服务均在双方自愿基础上进行，本店已尽到必要的安全操作与告知义务。如因未如实申报身体情况或擅自使用相关产品所引起的任何后果，本店概不承担法律责任。
All services are carried out voluntarily. The institution has fulfilled necessary safety and disclosure obligations. If consequences arise due to failure to disclose health conditions or unauthorized product use, the institution bears no legal liability.
Signature

Powered by Jotform SignClear
日期 Date of Signing*

MonthDayYear
Date
养生保健服务免责声明及注意事项
Disclaimer and Precautions for Health Preservation and Wellness Services

一、免责声明 Disclaimer
1，本店提供的为传统中医特色及综合养生保健项目，旨在通过温和调理手法与自然方式，起到舒缓身心、促进气血流通、改善体质的作用。
Our institution provides traditional Chinese wellness and comprehensive health preservation services, aiming to relax the body and mind, promote circulation of qi and blood, and improve constitution.

2，本项目不属于临床治疗或医学行为，不作为任何疾病的诊断、治疗手段或替代医疗方案。若您患有明确疾病，建议在专业医师指导下接受治疗。
These services do not constitute clinical treatment or medical behavior, and are not intended for diagnosis, treatment, or as a substitute for medical care. If you have a diagnosed condition, please seek advice from professional medical staff.

3，在服务过程中，部分顾客可能出现以下“调理反应”，属身体自我调整与代谢活跃的正常表现：
During the service, some clients may experience the following normal responses, which reflect self-adjustment and active metabolism:
- 短暂疲倦、乏力或嗜睡 Temporary fatigue, weakness, or drowsiness
  微热、出汗、口干、排便增多 Mild fever, sweating, dry mouth, or increased bowel movements
- 局部皮肤发红、发痒、轻微水泡或色素沉着 Local skin redness, itching, mild blisters, or pigmentation
- 旧病部位出现酸胀、隐痛、情绪波动、烦躁或轻微头晕 Soreness, dull pain at old illness sites, mood swings, irritability, or slight dizziness
- 上述现象通常在数小时至2-3日内自行缓解。如有明显不适，请及时告知工作人员或咨询医生。These reactions usually subside within a few hours to 2–3 days. If severe discomfort occurs, please inform staff or consult a doctor.
4，服务过程中需配合服务人员操作，如因擅自移动身体、擅自调整工具或干扰操作而导致意外（如烫伤、水泡、症状加重等），本人自愿承担由此引发的后果与责任。
I clearly understand that I must cooperate with the staff during the service. If I move, adjust tools, or interfere, leading to accidents (e.g., burns, blisters, symptom aggravation), I shall bear full responsibility.

5，本机构及服务人员对因本服务产生的任何直接或间接损失概不负责，法律另有规定除外。
The institution and its service personnel shall not be liable for any direct or indirect losses caused by this service, except as otherwise provided by law.

6，我们会严格保护您的隐私信息，仅用于服务相关用途，未经许可不会向第三方透露。
We will strictly protect your private information, which will only be used for service-related purposes and will not be disclosed to third parties without permission.

7，在服务过程中，可能会拍照或录像用于操作记录、内部培训或宣传推广。涉及面部或其他隐私信息时，会进行打码处理。如您对拍摄有特殊要求或不同意用于宣传，请提前告知工作人员。
During the service, photos or videos may be taken for documentation, internal training, or promotional purposes. Any facial or private information will be obscured. If you have special requests or do not consent to your images being used for publicity, please inform our staff in advance.

8，本声明及相关服务均遵守美国联邦及加州法律法规。
This disclaimer and related services comply with the laws and regulations of the United States and the State of California.
本人已阅读并理解以上《免责声明及注意事项》，并确认已如实告知个人健康情况。本人自愿接受相关养生保健服务，并同意遵守本声明。
I have read and understood the above “Disclaimer and Precautions,” and confirm that I have truthfully disclosed my health conditions. I voluntarily accept the relevant wellness services and agree to abide by this disclaimer.
签字 Signature to Acknowledge Waiver*

Powered by Jotform SignClear
日期 Date of Signing*

MonthDayYear
Date
其他 Additional Comments or Questions
本人已阅读并理解以上《免责声明及注意事项》，自愿接受相关养生保健服务，并同意遵守本声明。I have read and understood the waiver and agree to proceed.*

I agree and accept the terms of the waiver.
Should be Empty: