top of page

Client Consent

Client Information

Date of Birth

Health Information Disclosure

Please indicate if you have any of the following conditions by checking the appropriate box:
Are you pregnant?
Yes
No
Do you have any allergies?
Yes
No
If yes, please specify:
Do you any have skin conditions?
Yes
No
If yes, please specify:
Did you have any surgies recently?
Yes
No
If yes, please specify:

Health Information Disclosure:

I understand that it is important to disclose any relevant health information that may affect my treatment. I agree to provide accurate and complete information regarding my health, including any medical conditions, medications, allergies, or previous injuries.

Confidentiality:

Imperial Retreat is committed to protecting my privacy and confidentiality. I understand that my personal and health information will be kept confidential and will not be disclosed without my consent, except as required by law.

Risks and Benefits:

I acknowledge that while the services provided by Imperial Retreat are designed to promote wellness, there may be some risks associated with certain treatments and activities. I understand that it is my responsibility to inform the staff of any discomfort or concerns during my sessions.

Cancellation and Refund Policy:

I understand and agree to the cancellation and refund policies as stated by Imperial Retreat. I acknowledge that failure to comply with these policies may result in fees or forfeiture of payment.

Release of Liability:

I release and hold harmless Imperial Retreat, its employees, and agents from any and all claims, demands, damages, or causes of action arising out of or in connection with my participation in the treatments, services, and activities offered.

Client Acknowledgment:

I have read and understand the information provided in this consent form and consent to participate in the treatments, services, and activities provided by Imperial Retreat.

Date
bottom of page