Existing Patients, please complete the form below to check-in for your upcoming appointment

I knowingly, voluntarily, and intelligently request and consent to receive the Bellanina Face Massage from Sierra’s Bodyworx (“Provider”). I acknowledge and understand that the Bellanina Face Massage is a non-medical facial massage and cosmetic wellness service intended to promote relaxation, lymphatic stimulation, and aesthetic appearance. The service is not a medical procedure and does not constitute medical treatment, diagnosis, or advice. No representations, warranties, or guarantees have been made regarding results, and individual results may vary.

I acknowledge that participation in facial massage services involves inherent and potential risks, whether known or unknown, including but not limited to temporary redness, sensitivity, flushing, swelling, tenderness, light bruising, muscle soreness, sinus drainage, headache, or temporary skin irritation. I expressly assume all risks associated with the Bellanina Face Massage, whether foreseeable or unforeseeable, and accept full responsibility for any outcomes or reactions.

I represent and warrant that I have fully disclosed all relevant medical history and conditions, including but not limited to recent facial surgery or cosmetic procedures; injectable fillers or neurotoxins; active acne, rosacea, dermatitis, or skin infections; open wounds or lesions; blood clotting disorders; use of blood-thinning medications; neurological or vascular conditions; or any other condition that may be affected by facial massage. I acknowledge that the Provider relies on the accuracy of this information and that any failure to disclose or misrepresentation of medical information releases the Provider from any and all liability for resulting injury or damages.

To the fullest extent permitted by law, I hereby knowingly and expressly release, waive, acquit, satisfy, and forever discharge Sierra’s Bodyworx, its owner, employees, independent contractors, representatives, successors, and assigns from any and all claims, demands, causes of action, damages, losses, costs, or liabilities of any kind, whether in law or equity, whether known or unknown, suspected or unsuspected, arising out of or related in any way to the Bellanina Face Massage services, including claims arising from the ordinary negligence of the Provider. This release is intended to be as broad and inclusive as permitted under Florida law and shall be binding upon my heirs, executors, administrators, successors, and assigns.

I acknowledge that Sierra’s Bodyworx operates in accordance with applicable provisions of Florida Statutes Chapter 480 (Massage Practice Act) and that Bellanina Face Massage services are provided strictly within the scope of licensed massage therapy and non-medical cosmetic bodywork services. I understand that the Provider does not render medical opinions or advice and that I have been advised to consult with a licensed healthcare professional regarding any medical or dermatological concerns prior to receiving services.

Privacy and Confidentiality Notice: Sierra’s Bodyworx maintains the confidentiality of client personal and health-related information in accordance with applicable Florida law, including but not limited to Florida Statutes §§456.057 and 501.171, as applicable. Client information is collected and used solely for treatment documentation, scheduling, billing, and lawful business operations. Records are maintained in a secure manner and disclosed only with written authorization or as required by law. Sierra’s Bodyworx is not a covered entity under the Health Insurance Portability and Accountability Act (HIPAA); however, it implements HIPAA-consistent administrative, technical, and physical safeguards to protect client information.

By receiving Bellanina Face Massage services, I acknowledge that I have read and fully understand this document, that I understand I am waiving substantial legal rights, including the right to sue, and that I voluntarily agree to be bound by its terms under the laws of the State of Florida.

SIERRA’S BODYWORX
BELLANINA FACE MASSAGE INFORMED CONSENT, ASSUMPTION OF RISK, RELEASE, AND PRIVACY NOTICE

I knowingly, voluntarily, and intelligently request and consent to receive the Bellanina Face Massage from Sierra’s Bodyworx (“Provider”). I acknowledge and understand that the Bellanina Face Massage is a non-medical facial massage and cosmetic wellness service intended to promote relaxation, lymphatic stimulation, and aesthetic appearance. The service is not a medical procedure and does not constitute medical treatment, diagnosis, or advice. No representations, warranties, or guarantees have been made regarding results, and individual results may vary.

I acknowledge that participation in facial massage services involves inherent and potential risks, whether known or unknown, including but not limited to temporary redness, sensitivity, flushing, swelling, tenderness, light bruising, muscle soreness, sinus drainage, headache, or temporary skin irritation. I expressly assume all risks associated with the Bellanina Face Massage, whether foreseeable or unforeseeable, and accept full responsibility for any outcomes or reactions.

I represent and warrant that I have fully disclosed all relevant medical history and conditions, including but not limited to recent facial surgery or cosmetic procedures; injectable fillers or neurotoxins; active acne, rosacea, dermatitis, or skin infections; open wounds or lesions; blood clotting disorders; use of blood-thinning medications; neurological or vascular conditions; or any other condition that may be affected by facial massage. I acknowledge that the Provider relies on the accuracy of this information and that any failure to disclose or misrepresentation of medical information releases the Provider from any and all liability for resulting injury or damages.

To the fullest extent permitted by law, I hereby knowingly and expressly release, waive, acquit, satisfy, and forever discharge Sierra’s Bodyworx, its owner, employees, independent contractors, representatives, successors, and assigns from any and all claims, demands, causes of action, damages, losses, costs, or liabilities of any kind, whether in law or equity, whether known or unknown, suspected or unsuspected, arising out of or related in any way to the Bellanina Face Massage services, including claims arising from the ordinary negligence of the Provider. This release is intended to be as broad and inclusive as permitted under Florida law and shall be binding upon my heirs, executors, administrators, successors, and assigns.

I acknowledge that Sierra’s Bodyworx operates in accordance with applicable provisions of Florida Statutes Chapter 480 (Massage Practice Act) and that Bellanina Face Massage services are provided strictly within the scope of licensed massage therapy and non-medical cosmetic bodywork services. I understand that the Provider does not render medical opinions or advice and that I have been advised to consult with a licensed healthcare professional regarding any medical or dermatological concerns prior to receiving services.

Privacy and Confidentiality Notice: Sierra’s Bodyworx maintains the confidentiality of client personal and health-related information in accordance with applicable Florida law, including but not limited to Florida Statutes §§456.057 and 501.171, as applicable. Client information is collected and used solely for treatment documentation, scheduling, billing, and lawful business operations. Records are maintained in a secure manner and disclosed only with written authorization or as required by law. Sierra’s Bodyworx is not a covered entity under the Health Insurance Portability and Accountability Act (HIPAA); however, it implements HIPAA-consistent administrative, technical, and physical safeguards to protect client information.

By receiving Bellanina Face Massage services, I acknowledge that I have read and fully understand this document, that I understand I am waiving substantial legal rights, including the right to sue, and that I voluntarily agree to be bound by its terms under the laws of the State of Florida.