Your health
Tick anything that applies to you, or “None of these.”
The agreement
Please read before signing.
What this is
A Champi ritual: a relaxing massage of the scalp, hair, forehead, neck and shoulders using oils such as coconut, argan, sesame or jojoba, sometimes with essential oils. It is for relaxation only, not medical treatment.
Possible risks
An allergic reaction or skin irritation, oil getting into eyes, ears or nose, brief soreness, headache or dizziness, effects on colored or treated hair, oily hair afterwards, and stained clothing.
Your part
The health information you give is true. You’ll tell your therapist about any change, or right away if anything hurts, burns, itches or makes you dizzy. You can change the pressure or stop at any time.
Release
You choose this service and accept its risks. As far as New Jersey law allows, you release Champi and its owners and staff from claims arising from the service, including reactions to oils, except for gross negligence or willful misconduct. This also binds your heirs and legal representatives.
Emergencies and privacy
In an emergency, staff may call 911, and you’re responsible for resulting medical costs. Your information stays confidential and is used only to keep your service safe, unless the law requires otherwise.
Future visits
This waiver covers your future visits until you cancel it in writing. If your health changes, you’ll fill out a new one. If any part can’t be enforced, the rest still applies. New Jersey law governs this agreement.
Sign
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Parent or guardian
The client is under 18, so a parent or guardian signs on their behalf.
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