This agreement you allow to have a spa treatment or service with our Licensed Massage Therapist, Esthetician and/or Nail Technician. I give permission to receive spa service(s), treatment(s) and/or therapy, which includes massages, facials, body treatments (including body wraps and scrubs), and/or nails. I understand that therapeutic massages, facials, body treatments, or nail services are not a substitute for traditional medical treatment or medications. I understand that my professional licensed massage therapist, esthetician, and/or nail technician does not diagnose illnesses, injuries, or prescribes medications. I have clearance from my physician to receive massage therapy, and/or spa services to the skin, face, back and/or body. I understand the risks associated with massage therapy such as superficial bruising, short term muscle soreness and exacerbation of undiscovered injury. I therefore release the company and the individual massage therapist, esthetician, and/or nail technician from all liability concerning these injuries that may occur during the massage session. I understand the risks associated with applying topical oils, chemicals, lotions and/or heat to my skin during a facial, body treatment, and/or nail service. I therefore release the company and the individual massage therapist, esthetician, and/or nail technician from all liability concerning any skin irritations, infections, redness, future breakouts, rashes, and/or swelling that may occur during a facial, body treatment and/or nail session. I understand the importance of informing my massage therapist, esthetician, and/or nail technician of all medical conditions and medications I am taking, and to let the massage therapist, esthetician, and/or nail technician know about any changes of these. This information will also be on my profile in the notes section. I understand that there may be additional risks based on my physical condition. I understand that it is my responsibility to inform my massage therapist, esthetician, and/or nail technician of any discomfort I may feel during the massage session, facial treatment, body treatment, and/or nail session, so he or she may adjust accordingly. I understand that I or the massage therapist, esthetician, and/or nail technician may terminate the session at any time if the session is inappropriate. I have been given a chance to ask questions about the spa services and my questions have been answered. Draping will be used during the massage session and body treatments - only the area worked on will be uncovered.Please note if your location is more than 25 miles, there is an additional fee of $25 per massage therapist and/or esthetician and/or nail technician per 25 miles traveled. We also have a 48-hour cancellation notice or change date/time/location request, otherwise you could be charged 50% of the total appointment value. *

I agree to the terms and conditions listed under the consent and release form.

Have you or any member of your household been diagnosed with any contagious inflections including but not limited to COVID-19, strep throat, or the flu WITHIN THE PAST 14 DAYS? *

Yes

No

Do you understand that Balance Mobile Spa, LLC cannot be held liable for any exposure to the COVID-19 virus and or any other contagious inflections caused by misinformation on this form or the health history provided by each client? *

Yes

No

Balance Mobile Spa, LLC is following these enhanced procedures to prevent the spread of COVID-19: *

- Prepayment for services available if clients prefer contactless checkout - Additional time included between appointments to prevent guest contact with each other - Guests accompanying those scheduled for services are not permitted - Each guest is required to wash hands upon arrival and before leaving - Your Technician will thoroughly clean hands and wear sterile gloves during all consultations and treatments - Your Technician will wear the following protective gear: mask, and (optional) face guard for each appointment - All skincare product bottles used during treatment will be placed in a separate container for disinfection and disposable items will be used when possible - All surfaces will be wiped thoroughly with hospital grade disinfectant before and after each client according to the manufacturer's directions, and sterilized with a professional steam-sterilization equipment at the end of each day

I agree to each statement above and release Balance Mobile Spa, LLC from any and all liability for the unintentional exposure or harm due to COVID-19.

Sign *

Typing your name below, serves as your signature that all of your answer have been truthful to the best of your knowledge.

First Name

Last Name

Date *

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Address *

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Phone *

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