Personal Information

Full Name Date of Birth Email Address Phone Number

Health Information

Please list any allergies, medical conditions, or medications: Are you currently pregnant? Do you have sensitive skin or any skin conditions?

Waiver and Release

I understand that body wrap services are not a substitute for medical treatment and are not intended to diagnose, treat, or cure any medical condition. I affirm that I have stated all known medical conditions and answered all questions honestly. I acknowledge that my participation is voluntary and I release the service provider from any liability.

I have read and agree to the above waiver.

Signature Date

Body Wrap Service Waiver

Personal Information

Health Information

Waiver and Release