I ____________________________________ understand, have read and completed this 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 acknowledge that the practice of skin care including microdermabrasion, waxing, body treatments, chemical peels and various other beauty procedures are not an exact science and no specific guarantees can or has been made concerning the expected results. Some clients experience more change and improvements than others. In virtually all cases, multiple treatments are required to benefit from the desired results. I also understand that the following risks and hazards may occur in connection with any particular treatment including but not limited to: Unsatisfactory results, poor healing, discomfort, redness, blistering, nerve damage, scarring infection, change in skin pigmentation, allergic reaction, and increase hair growth. I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to indemnify, hold harmless and release from any and all liability White Lotus Day Spa as well as any owners, officers, directors, assigns, insurers, independent contractors or employees of the above company for any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive. I understand that White Lotus Day Spa staff members have the right to refuse service if any client’s conduct is disruptive or inappropriate. I understand that if I cancel an appointment less than 24 hours in advance or am late for an appointment I may be charged for the full scheduled session.
*If minor, signature of legal parent or guardian
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