Weightloss/Detox Wrap Information Form


Please complete the form below prior to your appointment. All information is kept strictly confidential. Thank you.

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I am requesting this service on my own initiative and I acknowledge that the therapist and Main Street Spa & Wellness Center do not diagnose ailments or prescribe treatments. Because bodywraps should not be done under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile, and I understand there shall be no liability on the practitioners’ part should I forget to do so. It is further understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment for the “Full” scheduled appointment. My signature below indicates that I hereby release Main Street Spa & Wellness Center and their staff from any liability for claims arising from the use of services. We reserve the right to restrict or refuse any client.


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