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Ear Seeding Intake and Waiver

Please fill out the following form so we may prepare your session

I understand that auricular therapy is a generally safe method of treatment that involves the insertion of ear seeds in the auricular region.

I acknowledge that it may occasionally have some side effects including bruising, numbness, tingling or pain near the ear seeds lasting several days, as well as dizziness or fainting.

Unusual risks of acupressure include spontaneous miscarriage and nerve damage.

Emotional release and regression to past traumatic events may also result from any or all aspects of treatment. 

I understand that while the list above describes major risks of treatment, other side effects and risks may occur that are not listed. 

I intend this consent and release form to cover this and any future events that I participate in for auricular therapy. 

As with any health-related treatment, I understand that it is impossible to accurately predict how any one person may respond to treatment and I acknowledge that there may be other 

effects not listed on this consent form. 

I understand that auricular therapy is not a replacement for diagnostic medical procedures. 

This healing session is not intended to treat or diagnose a condition. 

I hereby release and agree to hold Soul Shine LLC harmless from, and waive on behalf of myself, my heirs and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Soul Shine LLC.

I understand that this release discharges Soul Shine LLC from any liability or claim that I, my heirs, or any personal representatives may have against the store with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Soul Shine LLC.

This liability waiver and release extends to the store together with all owners, partners, and employees.

I confirm that I understand and have read the above 

Thanks for submitting!

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