Disclosure, Consent and Liability | MK Scalp and Wellness Lounge

MK Scalp and Wellness Lounge
DISCLOSURE, CONSENT & LIMITED LIABILITY AGREEMENT
MK Scalp and Wellness Lounge appreciates your patronage. Please read and fill out this Disclosure, Consent and Liability Agreement completely, making certain that all information is filled out correctly and to the best of your knowledge.

First Name *

Last Name *

Phone *

Email *

Address

Street Address *

City *

State *

Country *

Postal Code *

Medical Profile Questions:
Please answer these questions to the best of your abilities:

Are you under the age of 18? *

Yes

No

Any topical allergies to products, metals or anything else you feel necessary to share? (If none, please put No or N/A) *

Have you had any aspirin or blood thinners in the past week? *

Yes

No

Are you on any immunosuppressive medications such anti-inflammatories or steroids? *

Yes

No

Do you have a history of cold sores, herpes, or fever blisters? *

Yes

No

Are you sensitive/allergic to latex? *

Yes

No

Is there any history of skin diseases or remarkable skin sensitivities? *

Yes

No

If yes, please share here:

Have you had a chemical peel or laser? *

Yes

No

If yes, please indicate here when you had your last chemical peel or laser:

Do you have problems healing? *

Yes

No

Are you currently pregnant? *

Yes

No

Are you currently undergoing radiation or chemotherapy? *

Yes

No

If yes, has it been more that 72 hours since your last treatment?

Do you wear contact lenses? *

Yes

No

MK Scalp and Wellness Lounge Services:
This Disclosure, Consent, and Limited Liability Agreement (“Agreement”) is entered into between MK Scalp and Wellness Lounge (“Provider”) and the undersigned client (“Client”) in connection with scalp facial and related wellness services.

1. Service Disclosure & Client Understanding

I understand and acknowledge that I am receiving scalp facial and scalp wellness services provided by MK Scalp and Wellness Lounge. These services are cosmetic and wellness-based in nature and are intended to support scalp health, relaxation, and overall scalp wellness.

I acknowledge that:

Every scalp is unique, and results may vary from person to person
No specific results or outcomes are guaranteed
MK Scalp and Wellness Lounge does not diagnose, treat, cure, or prevent any medical or dermatological conditions

If any condition is observed that may indicate a potential scalp or skin concern outside the scope of cosmetic services, I understand that I may be referred to an appropriate licensed medical or dermatological professional for further evaluation.

1. Service Disclosure & Client Understanding *

I acknowledge and understand.

2. Medical Disclaimer

I acknowledge and understand that MK Scalp and Wellness Lounge:

Does not practice medicine
Does not provide medical diagnoses or treatments
Does not accept or bill health insurance

I confirm that I have disclosed all relevant health information, sensitivities, allergies, scalp conditions, or medical concerns prior to receiving services. I understand that MK Scalp and Wellness Lounge relies on the information I provide to assess my suitability for services.

2. Medical Disclaimer *

I acknowledge and understand.

3. Photo & Video Consent

I understand and acknowledge that photos and/or videos may be taken before, during, and/or after my service for the following purposes:

Documentation of results
Educational use
Social media content
Marketing and promotional materials

I understand that:

My identity will never be intentionally misrepresented
I may opt out of photo and/or video use at any time by notifying MK Scalp and Wellness Lounge verbally or in writing
Opting out will not affect my ability to receive services

3. Photo & Video Consent *

I acknowledge and understand.

4. Opportunity for Questions & Informed Consent

I confirm that:

I have been given the full opportunity to ask questions regarding my service
All questions have been answered to my satisfaction
I fully understand the nature of the services I am receiving

By signing this Agreement, I knowingly and voluntarily consent to receive scalp facial and scalp wellness services from MK Scalp and Wellness Lounge.

4. Opportunity for Questions & Informed Consent *

I acknowledge and understand.

5. Appointment Policies & Client Responsibilities

I understand and agree to the following policies:

I agree to arrive 10–15 minutes early for my scheduled appointment
Arriving more than 10 minutes late may result in a $25 late fee
Arriving more than 20 minutes late may require rescheduling
Cancellations or rescheduling must be made at least 48 hours in advance to avoid a cancellation fee of up to 100% of the reserved service cost
A no-show fee may be charged for missed appointments, not to exceed the full service price
For safety, insurance, and space limitations, no children or additional guests are permitted during appointments. Failure to comply may result in rescheduling

5. Appointment Policies & Client Responsibilities *

I acknowledge and understand.

6. No Refund Policy

I understand and agree that:

All sales are final
There are NO REFUNDS or partial refunds for services once rendered
Fees paid reserve professional time and resources and are non-refundable under any circumstances after service completion

6. No Refund Policy *

I acknowledge and understand.

7. Assumption of Risk & Limited Liability

I acknowledge that I voluntarily assume all risks associated with scalp facial and scalp wellness services, including but not limited to temporary irritation, sensitivity, or unexpected reactions.

I hereby release, waive, and hold harmless MK Scalp and Wellness Lounge, its owners, employees, contractors, and affiliates from any liability, claims, or damages arising from services rendered, except in cases of gross negligence.

This Agreement constitutes the entire agreement between the Client and MK Scalp and Wellness Lounge and supersedes all prior oral or written agreements. Any modifications must be made in writing and signed by both parties.

7. Assumption of Risk & Limited Liability *

I acknowledge and understand.

8. Final Acknowledgment & Agreement

By signing below, I acknowledge, understand, and agree that:

The staff at MK Scalp and Wellness Lounge does not practice medicine, does not accept health insurance, and has made no representation to the contrary
The information I have provided is accurate and complete to the best of my knowledge
MK Scalp and Wellness Lounge is not responsible for complications arising from incorrect or omitted information
The information provided will be used to assess my suitability for scalp facial and wellness services
MK Scalp and Wellness Lounge reserves the right to refuse services if, in their professional judgment, the service is deemed unsafe, unethical, or too high-risk

8. Final Acknowledgment & Agreement *

I acknowledge and understand.

Client Name (Printed) *

Client Signature *

Clear

Date of Signing: *

Medical Profile Questions:Please answer these questions to the best of your abilities:

MK Scalp and Wellness Lounge Services:This Disclosure, Consent, and Limited Liability Agreement (“Agreement”) is entered into between MK Scalp and Wellness Lounge (“Provider”) and the undersigned client (“Client”) in connection with scalp facial and related wellness services.

1. Service Disclosure & Client Understanding

2. Medical Disclaimer

3. Photo & Video Consent

4. Opportunity for Questions & Informed Consent

5. Appointment Policies & Client Responsibilities

6. No Refund Policy

7. Assumption of Risk & Limited Liability

8. Final Acknowledgment & Agreement

Medical Profile Questions:
Please answer these questions to the best of your abilities:

MK Scalp and Wellness Lounge Services:
This Disclosure, Consent, and Limited Liability Agreement (“Agreement”) is entered into between MK Scalp and Wellness Lounge (“Provider”) and the undersigned client (“Client”) in connection with scalp facial and related wellness services.