Hydrotherapy Consent Form


 

Lavender Falls Face & Body Spa

Client Informed Consent Form

Hydrotherapy (Water) Treatments

 

PLEASE READ CAREFULLY & COMPLETELY

 

19239 Stone Oak Pkwy Suite # 201

San Antonio, Texas 78258

Phone: 210-446-0903

www.sanantonio.lavenderskinspa.com

Online Booking Available

Treatment Consists of:

Water can be used therapeutically in a number of ways, forms of hydrotherapy include: 

Whirlpools - These soaking tubs use warm water and jet streams to massage and relax the body.

Vichy Shower - During the treatment, you lie on a padded table while water showers the body. A rainbar with multiple shower jets positioned above you is customized for specific location and temperature. Alternating hot & cold temperatures may be used during treatment.

Vichy shower is often a complement to massages, wraps and scrubs.

Clients Acknowledgements:

Hydrotherapy treatments are not recommended for individuals with the following:

Serious heart conditions, Diseases of the circulatory system, Nervous system conditions, or Systemic conditions. Oncological diseases, Infectious diseases, or if you are prone to bleeding.

Open wounds and skin rashes.

Information: I acknowledge I am not currently nor have used any of the products listed below within the time frame listed.

Pre-Treatment Acknowledgement

           ·   Allergies I am not allergic to any of the ingredients in the treatment.

            ·    Sunburn or Sun Exposure- 1 week prior to treatment.

            ·    Recent Laser Treatments or Chemical Peels

            ·    Pregnant or Breastfeeding

            ·    Chemotherapy or radiation therapy

 

*Notify your aesthetician of any medical conditions & medications (Current & within the last 90 days).

Post-Treatment Acknowledgement

          ·   Client may resume normal activities unless otherwise directed by Aesthetician.

         ·  Due to accelerated detoxification of the body you may experience temporary side effects such as nausea, headaches and dizziness.

If you experience mild side effects:

         ·  Relax at a comfortable temperature to normalize body temperature.

         ·  Drink water to rehydrate the body.

         ·  If side effects persist contact your Aesthetician immediately.

Side Effects:

Possible side effects include but are not limited to:

Allergic reaction known as contact dermatitis for some patients using essential herbs and oils in their bath water.

Elevated body temperature

Nausea

Dizziness

Dehydration

Headaches

There may be risks not yet known at this time.

Acknowledgements:

           ·           I understand that any time the skin barrier is compromised; there is a small risk of infection. I will contact my aesthetician immediately should this happen.

           ·           The treatment has been fully explained and any questions or concerns that I have, have been addressed.

          ·            I acknowledge that no guarantee has been given to me as to the condition of the complexion, skin pore size, wrinkles or the percentage of improvement expected following treatment, due to each individual’s unique reactions.

          ·           I acknowledge this procedure is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied.

          ·         Photographs May be taken for comparison for future treatments for my chart.

 

I have read the above and understand it. My provider has answered my questions satisfactorily. I accept the possible risks and complications of the treatment.

 

I acknowledge that Lavender Falls Face and Body Spa has a no-refund policy on any products or service. There will be no refunds for any reason.

 

All services performed are without any guarantee. By continuing with service, you are confirming that you have read and understand our no refunds policy.

 

 

 

 

Lavender Falls Face and Body Spa

Thank you for choosing and trusting Lavender Falls Face and Body spa for your aesthetic needs.

Feel free to contact us at 210-446-0903 if you have any questions

           

 

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Signature Certificate
Document name: Hydrotherapy Consent Form
lock iconUnique Document ID: f2fdd9a631b196bccfad367ab656912ea16bfcb5
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December 9, 2017 1:16 pm CSTHydrotherapy Consent Form Uploaded by Lavender Falls Face and Body Spa LLC. - lavenderfallstx@gmail.com IP 162.198.97.65