PLEASE READ, INITIAL & SIGN AT THE BOTTOM

“I understand the benefits and risks of esthetics and give my consent for treatment.  I will consult my provider with any questions or concerns immediately. I understand the provider reserves the right to refuse services for reasons of safety or should my needs exceed the providers’ knowledge, skill, and abilities or scope of practice.” 

“I understand that treatment may include various esthetic tools to be used at the esthetician’s discretion such as but not limited to LED, high frequency wand, extraction tools, steam, exam light, Gua Sha, reflexology pen, facial cups, and Thai herbal poultice. I agree to let my esthetician know if I would not like certain tools used in my treatment.”   

“Gua Sha tools include, but are not limited to the use of a gemstone board of varied size and shape, beauty roller, mushroom, wand and/or spoon. These tools are used for Gua Sha Facial Rejuvenation and applied topically to the skin to move excess fluid, lift and sculpt, relieve symptoms, provide pain relief and increased mobility. These results are not guaranteed or permanent. Transitory petechiae (small red or purple dots), reddish areas, and muscle soreness can occur and should resolve within 48 hours.” 

“I will state all medical conditions and allergies that I am aware of and will keep my esthetician informed of any change. I give my consent to receive this service.”  

“I understand that Banya 5 has a no-tolerance policy for any sexual acting-out behavior.”  

“I consent for service, and products to be used topically on skin. All known allergies, sensitivities, medications, and medical diagnoses which may affect service have been disclosed above.” 

“If for any reason I feel my well-being is threatened or compromised or if I feel uncomfortable during the session, I agree to notify the therapist and management. I acknowledge I have full authority and responsibility regardless of the reason to determine if and when I may want the treatment paused, changed or stopped.”