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

Email

City

Date and time of appointment

Service Details:

Long hair, locs or extensions? Please detangle before your visit so we can spend your full time pampering you. Extra detangling that runs past your booked time may add a small surcharge.

For long hair or locs, we recommend a 90-minute package or longer. If your hair needs extra care, let us know ahead of time and we'll plan your session around it.

Every Hydration Head Spa includes a mini facial and mask, with the main focus on your scalp and hair.

If your package is on the shorter side, we may skip a step or suggest a little extra time so you never feel rushed.

Hair extensions, clip-ins and eyelash extensions are welcome! We'll go slow and be extra gentle. Because extensions can loosen with washing, we can't guarantee them, so please let us know in advance.

Are you pregnant?

Yes

No

Not applicable

If yes, how many weeks?

Expecting? Congratulations! We recommend a 60-minute session during pregnancy. You're also welcome to book a 90- or 120-minute package at your own risk, and we suggest checking with your doctor first. Need to pause, change position or take a break? Just let our team know anytime. We're happy to help.

Health check: any medical conditions, injuries (neck, back, arms, hands), allergies, recent surgery or medications? (e.g. high blood pressure, heart condition, seizures, skin conditions, Accutane/retinoids, blood thinners.) Write "None" if none. Need help or have a request? Please tell our team before or during your service.

To keep your clothes dry, we'll have a clean robe, dress or two-piece set ready for you (fits up to 4XL). Would you like to:

Use what Bella Gaïa provides

Wear my own loose, comfy clothing

Would you like us to use our products, or bring your own?

Use Bella Gaïa's products

Bring my own products

Anything else we should know? Share a special request or a personal note. We love hearing from you!

Service Acknowledgment and Consent:

Almost done! Please read the points below, then check the box:

• I have no contagious scalp, hair or health conditions (such as lice, ringworm or impetigo).

• Bella Gaïa is a head spa, not a massage parlor. Inappropriate or sexual requests will end the service.

• Services are for relaxation and cosmetic care only, not medical treatment. Results may vary. Mild risks such as skin irritation, allergic reaction or discomfort may occur, and I will tell my technician about any concerns.

• The health information I gave is true. Bella Gaïa is not responsible for reactions related to conditions, allergies or medications I did not disclose.

• Bella Gaïa is not responsible for lost or damaged jewelry, glasses or personal items.

• I agree to the spa policies (cancellation, late arrival, and gratuity not included in prices) at bellagaia.us/policies.

• RELEASE OF LIABILITY: I voluntarily choose to receive services at Bella Gaïa and understand the possible risks, including slips on wet surfaces, skin irritation, allergic reactions, and muscle, neck or back discomfort. To the fullest extent allowed by law, I release Bella Gaïa, its owner, staff and contractors from any claims for injury, illness or loss related to my services or visit, INCLUDING CLAIMS ARISING FROM THEIR OWN NEGLIGENCE, except for gross negligence or willful misconduct.

I have read and agree to all the terms above, including the Release of Liability, and I authorize Bella Gaïa to perform my chosen services.

If the client is under 18: I am their parent or legal guardian, I consent to these services, and I agree to all terms in this form on their behalf.

If the client is under 18: parent/guardian full name and relationship

Yes, send me Bella Gaïa specials and promotions by email and text message. Message frequency varies. Msg & data rates may apply. Reply STOP to opt out anytime.

May we capture your glow? We'd love to take headshot photos or videos of your session for training and social media (FB, IG, TikTok). No sensitive images, and we'll show you everything for your approval before anything is posted.

Yes, I'd love that!

No photos or videos, please

Signature

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