Acknowledgement Form

Business Address:

Bella Gaïa Hydration Head Spa

17398 Northwest Freeway, Jersey Village, Texas 77040

📱 Text: 713.909.9803 | 🌐 www.bellagaia.us

Client Information:

Name

Phone

City

Service Details:

Date and time of appointment

Is this service for:

Man

Woman

Other

Detangle your hair before arrival to avoid a surcharge if your session exceeds the booked time.
Additional detangling time may result in an extra fee.
For long hair or locs, book at least a 90-minute package. If your hair requires extra care, contact us in advance to adjust your booking.
Our Hydration Head Spa includes a mini facial and mask, but the primary focus is on hair care.
If your selected package is too short, some steps may be skipped, or additional time may be added.
We welcome customers with hair extensions, clip-ins, and eyelash extensions. However, there is no warranty on these services, and they are at your own risk. Rest assured, we will take it slow and be as gentle as possible. Please inform us in advance so we can accommodate you properly

Are you pregnant ?

Yes

No

I'm a man ! So NO

If yes, how many weeks?

Head spa treatments are generally safe, but we recommend consulting with your doctor to ensure it is suitable for you. If you are pregnant, we advise not to exceed 60 minutes for a head spa session.

Do you have any prior hands, arms, or spinal and neck injury?

Yes

No

Where ? Do you need help ?

Are you allergic or sensitive to any beauty products?

Yes

No

If yes, please specify:

Do you have any thyroid issues that would exclude red light therapy?

Clothing Preferences:

For women, We provide a clean, comfortable open-shoulder dress or a two-piece set (shorts & top, fits up to 3XL) to prevent your clothes from getting wet. You may choose to:

Use what Bella Gaia provides

Wear your own loose and accessible clothing

We provide a clean short, throw-over robe (fits up to 4XL). No top is provided. You may choose to:

Use what Bella Gaia provides

Wear your own loose and accessible clothing

Product Preferences:

Would you preter to use our products or bring your own?

Use what Bella Gaia's products

Bring my own products

Are you here to celebrate a special occasion?

Yes

No

Media :

I allow Bella Gaia to take headshot photos or videos of my Hydration Head Spa session for training and social media (FB, IG, TikTok). No sensitive images will be shown. Bella Gaid will show me the images for my final verbal approval before public use

Yes, i'm ok with taking video photo of me

No, don't take photo video of me

We value your teedback and any special requests you may have. Please feel free to leave a personal note for us:

Service Acknowledgment and Consent:

I declare that I do not have any scalp or hair issues that could be contagious to staff members or other clients, such as: Lice, Ringworm (Tinea capitis), Impetigo

I also declare that I do not have any other contagious health issues that could affect others.

I understand that Bella Gaia is a head spa, not a massage parlor. Bella Gaia reserves the right to cancel or refuse service for any inappropriate or sexually related requests.

I authorize BELLA GAÏA, Hydration Head Spa to perform the services I have chosen.

I release Bella Gaia from any liability in the event of an accident, illness, or injury caused by myself or other customers.

I have read and fully understand the contents of this Pre-Online Check-In and Waiver form. I voluntarily agree to the terms and conditions stated above.

I understand that Bella Gaia’s Hydration Head Spa is designed for relaxation, but minimal risks (such as skin irritation, allergic reactions, or mild discomfort) may occur. I agree to inform my technician of any concerns during my session.

Signature

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BELLA GAÏA

HYDRATION HEAD SPA

Acknowledgement Form