Healthcare Spa Agreement

HEALTHCARE SPA AGREEMENT

This Healthcare Spa Agreement (the Agreement) is entered into by and between Spa Name: and Client Name: , effective date: .

CLIENT INFORMATION

INSURANCE INFORMATION

MEDICAL HISTORY

Please check any of the following conditions that apply to you:

REQUESTED SERVICES

Please select the service(s) you are consenting to receive during this visit:

CONSENT TO TREATMENT

I, the undersigned, authorize the spa staff and licensed practitioners to perform the spa and clinical services selected above. I acknowledge that no guarantees have been made as to the results of any procedure. I understand that certain procedures may cause temporary redness, swelling, bruising, hyperpigmentation, hypo-pigmentation, scarring, infection, or allergic reaction. I have advised the provider of all known medical conditions and medications that could affect treatment, and I agree to follow pre- and post-treatment instructions provided by the facility.

I understand that some services may require referral to or performance by a licensed medical professional. I consent to the administration of such services by qualified personnel and understand that consultations and additional medical consent forms may be required for invasive or medical procedures.

RISKS, BENEFITS, AND ALTERNATIVES

The client acknowledges that the nature of the procedures, expected benefits, and reasonably foreseeable risks have been explained, including alternative treatment options and the option of no treatment. The client has had the opportunity to ask questions and understands that results may vary and may not meet the client’s expectations.

CANCELLATION, NO-SHOW, AND FEE POLICY

The client agrees to provide at least 24 hours notice to cancel or reschedule appointments. A cancellation or no-show fee may be assessed at the discretion of the spa when proper notice is not provided. Payment for services is due at the time of service unless other arrangements are confirmed in writing.

PHOTO / RECORDING AUTHORIZATION

I consent to the taking of clinical photography and/or digital imaging for documentation and treatment planning. Photographs will be used for treatment records and may be used for educational or promotional purposes only with my explicit written consent. I understand that identifying information will not be published without my additional authorization.

HIPAA / PRIVACY ACKNOWLEDGMENT

I acknowledge that I have been provided with privacy practices describing how my protected health information may be used and disclosed. I understand my rights with respect to my health information and consent to the spa’s use and disclosure of my protected health information for treatment, payment, and healthcare operations consistent with applicable law.

RELEASE AND INDEMNIFICATION

In consideration for the services provided, I hereby release, discharge and hold harmless the spa, its owners, employees, contractors and agents from any and all liability, claims, or demands arising from or related to the services provided, except for willful misconduct or gross negligence. I agree to indemnify and defend the spa from any claim or action based upon allegations arising out of my failure to disclose medical conditions or follow pre- or post-treatment instructions.

CLIENT CERTIFICATION

I certify that the information I have provided on this form is accurate and complete to the best of my knowledge. I understand that withholding information or providing false information may increase the risk of adverse outcomes. I agree to notify the spa of any changes in my medical history or medications prior to subsequent treatments.

Sign Now