Client Information + Consent Form

Client Information

First name

Last name

Phone

Birthday

Country/Region

Address

City

Zip / Postal code

Emergency Contact Name + Number

Health Information

Please answer the following to the best of your knowledge

Do you have any medical conditions or concerns that you believe may affect your ability to participate in Wellness Spa Sessions or receive guidance on Herbal Products at Venture Well? (e.g., heart conditions, epilepsy, pregnancy, etc.)

Yes

If Yes, please explain

Are you currently taking any medications or supplements? If yes please explain

Have you recently had any medical procedures, injuries or surgeries? If Yes, please explain

Any allergies; foods, essential oils, herbs, environmental, etc?

Venture Well Spa + Herbal Apothecary Consent Form

I understand that holistic healing services offered at Venture Well are not a substitute for medical or psychiatric diagnosis and treatment. Venture Well will not diagnose, treat, cure, or prevent any disease. Please consult your Dr and be aware of any contraindications with exiting conditions or prescription. I consent to receive treatments/herbal guidance from Jessy Raspiller.

Risks and Limitations: While offerings at Ventue Well are generally considered safe and non-invasive, it may not be suitable for everyone. Potential risks or limitations may include temporary discomfort, emotional release, or exacerbation of existing symptoms. It is important to communicate any discomfort or concerns during the treatment session.

Confidentiality: All information disclosed during the our session(s) will be kept confidential and will not be shared without your consent, except as required by law.

Signature

Client Information + Consent Form

Venture Well Spa + Herbal Apothecary Consent Form

Venture Well
Wellness Spa + Herbal Apothecary
1548 E Main St, Ventura, CA 93001

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