CLIENT INFORMATION & MEDICAL HISTORY
Welcome to Nyah Med Spa! We are looking forward to your first visit. Every new client must book a free initial consultation prior to treatment. This will allow us to assess your skin/hair type and perform a test spot with the laser to make sure you do not have any adverse reaction. You will be able to start your treatments 48 hours after the test spot.
In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.
PERSONAL HISTORY
Which of the following best describes your skin type?
I - Always burns, never tans
II - Always burns, sometimes tans
III - Sometimes burns, always tans
IV - Rarely burns, always tans
V - Brown, moderately pigmented skin
VI - Black skin
TREATMENT HISTORY
Have you ever had laser hair removal?*
Yes No
Have you used any of the following hair removal methods in the past six weeks?
Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories
Have you had any recent tanning or sun exposure that changed the color of your skin?*
Yes No
Have you recently used any self-tanning lotions or treatments?*
Yes No
Do you form thick or raised scars from cuts or burns?*
Yes No
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
Yes No
For our female clients:
Are you pregnant or trying to become pregnant?*
Yes No
Are you breastfeeding?*
Yes No
Are you using contraception?*
Yes No
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
Date:
Signature:
MEDICAL HISTORY
Are you currently under the care of a physician?*
Yes No
Are you currently under the care of a dermatologist?*
Yes No
Do you have any of the following medical conditions? (Please check all that apply)
Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?*
Yes No
Do you have any other health problems or medical conditions? Please list:
Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you experienced)
Client Treatment Consent and Release
I acknowledge that beauty treatments, the practice of skin care, and the practice of massage, including, but not limited to, microablation, microdermabrasion, waxing, electrolysis, facial toning, permanent cosmetics, body treatments, ionization, laser treatments, tattoo removal, vin treatments, brown spot removal, BOTOX, Collagen, Dermal Fillers, Sclerotherapy, Mesotherapy, Dermaplaning, and various other beauty procedures is not an exact science and no specific guarantees can or have been made concerning the outcome. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required in order to realize a difference.
I also understand and agree to assume the following risks and hazards which may occur in connection with any particular treatment including but not limited to: unsatisfactory results, soreness, poor healing, discomfort, redness, blistering, nerve damage, scarring, infection, change in skin pigmentation, allergic reaction, muscle damage, and increased hair growth. I understand that even tough precautions may be taken in my treatment, not all risks can be known in advance.
Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, hold harmless and release from any and all liability the company and the individual that provided my treatment, the insured, and any additional insureds, as well as any officers, directors, or employees of the above companies for any condition or result., known or unknown, that may arise as a consequence of any treatment that I receive.
I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect my treatment. I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration using a single arbitrator agreed to by both parties.
Date:
Signature:
SPA POLICIES
We respect your time and appreciate your choice to spend it with NYAH Med Spa. We've created our Spa Policies to provide the utmost versatility and convenience to our guests. Booking a reservation is your acceptance of our Spa Policies; therefore, please be certain you've reviewed and agreed to these terms.
Please respect our scheduling by keeping appointments whenever possible and providing a minimum of 24 hour notice when canceling or rescheduling appointments. Failure to comply with these guidelines will result in a loss of treatment or a fee of $25.
- Less than 24-hour notification to cancel or reschedule an appointment.
- No-show or missed appointments.
- Late arrivals - please keep in mind that arriving late for a service may require us to shorten the length of the treatment, with full charges applied, so as not to inconvenience other guests. We regret that late arrivals will not receive extension of scheduled appointments unless our schedule allows.
- We have a NO REFUND policy, however we will consider an exchange for other services.
- Vouchers are accepted from NEW CLIENTS ONLY; Vouchers from existing Clients will not be redeemed. We consistently offer extremely competitive in-house prices on our services and for this reason we can NOT extend any voucher exceptions to our existing clients.
Date:
Signature:
Microdermabrasion Client Informed Consent Form
Welcome to Nyah Med Spa! We are looking forward to your first visit. Every new client must book a free initial consultation prior to treatment. This will allow us to assess your skin/hair type and perform a test spot with the laser to make sure you do not have any adverse reaction. You will be able to start your treatments 48 hours after the test spot.
Client Name:*
1. I acknowledge having been informed that this cosmetic procedure is intended to remove surface layers of the skin to improve the vitality of the skin.*
I understand
2. I understand that my skincare professional can discover other, or different conditions that may require additional or different procedures than those planned. If my skincare professional discovers such other or different conditions I will be referred to appropriate medical care provider.*
I understand
3. I acknowledge that, while the goal of such a procedure is the removal of damaged skin, the realistic results average 50-75% improvement. I acknowledge that the practice of cosmetology is not an exact science and that no specific guarantees can or have been made concerning the expected result. Some clients are improved and in others no appreciable improvements is noticed.*
I understand
4. I also realize that the following risks and hazards may occur in connection with the particular procedure; worsening or unsatisfactory appearance, creation of additional problems such as: poor healing or skin loss, nerve damage, painful unattractive scarring, or recurrence or the original condition.*
I understand
5. I have been advised that I must use sunscreen of SPF 25 or greater at all times throughout the course of treatment.*
I understand
6. I have been informed that there are risks such as loss of blood and infection that are attendant to the performance of any exfoliation procedure.*
I understand
7. I have been advised of alternative methods available for my treatment, which includes acid peels and laser skin resurfacing.*
I understand
8. I acknowledge my obligation to follow the written and spoken instructions covering my pre and post treatment skincare regimen.*
I understand
9. I understand that multiple treatments may be required. The cost of these was disclosed prior to the first treatment.*
I understand
10. I have received a through explanation of my pre-exfoliation and post-exfoliation instructions. I understand these instructions and have received copies for reference. I understand that should I have additional questions, I should not hesitate to call.*
I understand
11. I certify that I have read the above consent and I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. I hereby consent to the Microdermabrasion procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.*
I understand
Pre - Microdermabrasion Instructions
- Avoid sun tanning or tanning creams/sprays for at least a week before treatment
- You must NOT have recently had laser surgery or used Acutance
- Candidates who have had a recent chemical peel or other skin procedure, such as collagen injections, should wait two to three weeks before undergoing Microdermabrasion.
- Prospective patients should also refrain from waxing or tanning the skin to be treated for a few weeks prior to Microdermabrasion treatment. Wash your face and neck with a non-oily, non-soap based cleanser before each scheduled treatment.
Post - Microdermabrasion Instructions
- The skin may feel tight as if exposed to the sun or wind for a day or two after treatment.
- The skin may look red and slightly swollen, ranging a few hours or more for sensitive skins.
- Keep the new skin clean and moisturized.
- Anti-inflammatory creams or cold compresses may be used as necessary
- Use a gentle cleanser.
- Trauma such as scratching or picking the treated area should be avoided.
- It is important to avoid irritating the treated skin with harsh chemicals, rubbing or tanning for one week.
- Although some peeling may occur in the treated areas, moisturizer should help minimize this effect.
- Avoid staying in the sun for at least 7 days after the Microdermabrasion treatment to prevent UV rays from damaging your skin which slows down the recovery.
- Patients who absolutely cannot avoid sun exposure should use a broad-spectrum sunscreen with an SPF of 30 or higher.
- Do not use glycolic, alpha hydroxyl, beta hydroxyl, retinol, benzyl peroxide or topical acne medications for 24-48 hours following treatment.
- You may resume prescription retinoid products (Retin A, Renova, Tretinoin, Avita, Alustra or other brands f Tretinoin and other prescription retinoid products (Adapalene, Avage, Differin, Tazorac, Tazarotene) 3-7 days after last Microdermabrasion treatment or as instructed by your technician.
WAIVER AND RELEASE OF LIABILITY
IN CONSIDERATION OF the risk of injury that exists while participating in MEDICAL SPA (hereinafter the "Activity"); and
IN CONSIDERATION OF my desire to participate in said Activity and being given the right to participate in same;
I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, "Releasor," "I" or "me", which terms shall also include Releasor's parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity; and
I HEREBY release and forever discharge NYAH MED SPA, located at 5755 N Point Pkwy Ste 55, Alpharetta, Georgia 30022, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively "Releasees"), from any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned Activity.
I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO: PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, DISFIGUREMENT, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS), ECONOMIC OR EMOTIONAL LOSS, AND DEATH. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS' NEGLIGENCE, CONDITIONS RELATED TO TRAVEL TO AND FROM THE ACTIVITY, OR FROM CONDITIONS AT THE ACTIVITY LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY.
I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs.
I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize Nyah Med Spa to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.
I FURTHER ACKNOWLEDGE that this Activity may involve a test of a person's physical and mental limits and may carry with it the potential for death, serious injury, and property loss. I agree not to participate in the Activity unless I am medically able and properly trained, and I agree to abide by the decision of the Nyah Med Spa official or agent, regarding my approval to participate in the Activity.
I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE Nyah Med SpaAND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST Nyah Med Spa FOR PERSONAL INJURY OR PROPERTY DAMAGE.
To the extent that statute or case law does not prohibit releases for ordinary negligence, this release is also for such negligence on the part of Nyah Med Spa, its agents, and employees.
I agree that this Release shall be governed for all purposes by Georgia law, without regard to any conflict of law principles. This Release supersedes any and all previous oral or written promises or other agreements.
In the event that any damage to equipment or facilities occurs as a result of my or my family's or my agent's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any such actions of neglect or recklessness.
THIS WAIVER AND RELEASE OF LIABILITY SHALL REMAIN IN EFFECT FOR THE DURATION OF MY PARTICIPATION IN THE ACTIVITY, DURING THIS INITIAL AND ALL SUBSEQUENT EVENTS OF PARTICIPATION.
THIS AGREEMENT was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both Participant, and Nyah Med Spa agree that this agreement is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted to alter or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.
In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.
In the event of an emergency, please contact the following person(s) in the order presented:
I, THE UNDERSIGNED PARTICIPANT, AFFIRM THAT I AM OF THE AGE OF 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. I CERTIFY THAT I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND ITS CONTENT AND THAT THIS RELEASE CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.
Signature
Date
Participant's Name:
Participant's Address:
Minor Participant's Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
PARENT / GUARDIAN WAIVER FOR MINORS
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I HEREBY CERTIFY that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Signature:
Date
Parent / Guardian Name:
Relationship to Minor:
Minor Participant's Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
PARENT / GUARDIAN WAIVER FOR MINORS
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I HEREBY CERTIFY that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Signature:
Date
Parent / Guardian Name:
Relationship to Minor:
Minor Participant's Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
PARENT / GUARDIAN WAIVER FOR MINORS
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I HEREBY CERTIFY that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Signature:
Date
Parent / Guardian Name:
Relationship to Minor:
Minor Participant's Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
PARENT / GUARDIAN WAIVER FOR MINORS
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I HEREBY CERTIFY that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Signature:
Date
Parent / Guardian Name:
Relationship to Minor:
Minor Participant's Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
PARENT / GUARDIAN WAIVER FOR MINORS
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I HEREBY CERTIFY that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Signature:
Date
Parent / Guardian Name:
Relationship to Minor:
Minor Participant's Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
PARENT / GUARDIAN WAIVER FOR MINORS
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I HEREBY CERTIFY that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Signature:
Date
Parent / Guardian Name:
Relationship to Minor:
Minor Participant's Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
PARENT / GUARDIAN WAIVER FOR MINORS
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I HEREBY CERTIFY that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Signature:
Date
Parent / Guardian Name:
Relationship to Minor:
Minor Participant's Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
PARENT / GUARDIAN WAIVER FOR MINORS
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I HEREBY CERTIFY that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Signature:
Date
Parent / Guardian Name:
Relationship to Minor:
Minor Participant's Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
PARENT / GUARDIAN WAIVER FOR MINORS
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I HEREBY CERTIFY that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Signature:
Date
Parent / Guardian Name:
Relationship to Minor:
Minor Participant's Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
PARENT / GUARDIAN WAIVER FOR MINORS
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I HEREBY CERTIFY that I am the parent or guardian of <CHILDFIRSTNAME> <CHILDLASTNAME>, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.
Signature:
Date
Parent / Guardian Name:
Relationship to Minor:
Ageless HydraFacial Treatment
PRE-CARE & POST-CARE INSTRUCTIONS
PRE-CARE INSTRUCTIONS:
• Avoid excess sun exposure, including tanning beds for 1 week before treatment. Always apply a broad spectrum sunscreen daily (SPF 30 or greater).
• Do not use any type of exfoliants (retinoic acid, tretinoin, retinol, benzoyl peroxide, glycolic acid, salicylic acid, astringents, etc.) 2 days before treatment.
• Avoid bleaching, waxing, tweezing, or using depilatory creams in the treatment area.
• Refrain from botox 5-7 days prior.
• Refrain from fillers 7-10 days prior.
• Refrain from any chemical peels or lasers for 30 days prior.
• Let your skincare specialist know if you have been diagnosed with cold sores or Herpes simplex.
• Drink water before and after. Well-hydrated clients will have the best results.
• Please arrive to your appointment without make-up, creams, gels, or lotions on treatment areas.
POST-CARE INSTRUCTIONS:
• You may wash your face the following morning. Under no circumstances should you pick at your face after a treatment. Doing so can lead to further irritation and even scarring.
• Avoid wearing make-up for at least 24 hours.
• Avoid excessive heat, tanning beds, steam rooms/saunas, and sun exposure for a minimum of 24 hours after treatment. If you must be in the sun, apply SPF 30 or greater - reapply every 2 hours, wear a hat, and seek shade when possible.
• Avoid vigorous activity and exercising for 24-48 hours after treatment.
• Do not use topical Retin-A for 2 days following treatment.
• Avoid facial waxing for 7 days.
• Please discuss continuing use of your regular skincare regimen post-treatment.
• Avoid surfaces that could irritate your skin such as: pillows, beards, collared or turtleneck shirts.
• Make sure you're using a clean pillowcase so dirt and oil doesn't clog pores when you sleep. The same goes for towels, or anything else that might come in direct contact with your face for an extended period of time.
• If you have any questions or concerns about anything whatsoever, please feel free to contact us so we can assist you.
Ageless HydraFacial Treatment Informed Consent
(Please read and initial each statement below)
HydraFacial is a hydradermabrasion treatment that combines cleansing, exfoliation, extraction, hydration and antioxidant protection simultaneously, resulting in clearer, more luxurious skin. The treatment is soothing, moisturizing, and non-invasive/non-irritating with little-to-no down time.
I, , hereby request and authorize my Esthetician/Technician with Nyah Med Spa, to preform HydraFacial treatments for me.
I have informed my Esthetician/Technician of any contraindications that I may have concerning this treatment. Contraindications include: Epilepsy, Melanoma/skin cancer, rosacea/telangiectasia. keloid scarring, active bacterial or fungal infections, bleeding disorders or blood thinning medication, immune suppression, aids, HIV, hepatitis, lupus, scars less than 3-6 months old, very thin skin, active sunburn, rashes, and/or any other chronic conditions.
I confirm that I am not pregnant, breastfeeding or lactating at this time, and that I have not taken isotretinoin (also known as Accutane) within the last 6 months. Additionally, I have not had chemotherapy or radiation treatments within the last 6 months, and I have completed a medical history checklist.
I have not had any excessive sun or UV exposer, and my skin does not feel sensitive or irritated in any way.
I have not recently undergone any of the following treatments:
• Botox, 5-7 days prior
• Fillers, 7-10 days prior
• Peels and lasers, 30 days prior
I have disclosed any known allergies I have and I acknowledge that if I am allergic to one or more of the ingredients in the products used, I may experience an allergic reaction.
I understand that I may experience temporary tingling, stinging, irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.
I will notify my Esthetician/Technician of any complications or concerns I may have as soon as they occur. I understand and agree that if I experience any issues or conditions due to my procedure that cause me to require medical care, I will consult a physician at my own expense.
I have informed the clinic of any use of oral or topical medications I may be using including Retinoids (Retin-A, Renova, Avita, Differin). Additionally, I acknowledge that I should avoid the use of Retin-A type products for a period of time recommend by my Esthetician/Technician pre- and post-treatment.
I understand that I should avoid waxing, the use of aggressive exfoliation, and products containing acids that are not part of the recommended home-care regimen in the treated areas for minimum 2 weeks pre- and post-treatment.
Use of sunblock protection (SPF 30 or greater) is necessary following all treatments. Failing to use sunblock will make me more susceptible to sunburn, sun damage, and hyperpigmentation.
I certify that I have been fully informed of the nature and purpose of the treatment, expected outcomes, and possible complications. Results will be visible immediately after treatment and skin may feel smooth and hydrated for 1 to 4 weeks (with appropriate home care to maintain treatment results), however, no guarantee can be given as to the final result obtained.
The information I have provided regarding my medical history is accurate to the best of my knowledge, and I affirm I do not have any ailments or conditions that would make this treatment/procedure incompatible with my health and wellbeing.
This service is a cosmetic treatment and no medical claims are expressed or implied.
I understand that this is a cosmetic treatment/procedure, and payment is my responsibility. This service is non-refundable.
By signing this form, I certify that I have read and fully understand the contents of this consent form; that I am at least 18 years of age, and fully competent to give my consent. I certify that The Esthetician/Technician has explained the nature of my condition, and I am fully aware that my condition is of cosmetic concern. The decision to proceed is based solely on my expressed desire to do so. I have received post procedure instructions and will strictly adhere to the given regimen_ I understand the procedure risks, benefits, and alternatives, including the likely results of not preforming the procedure. I acknowledge I have been given the opportunity to ask any questions I may have, and those questions have been answered. I duly authorize the Esthetician/Technician to preform HydraFacial treatments for me, as well as any post treatment requirements that may be necessary. I understand my Esthetician/Technician will take every precaution to minimize or eliminate negative reactions as much as possible, and I agree to inform my Esthetician/Technician if I experience any pain, discomfort, or sensitivities during treatment, allowing for them to make the appropriate adjustments. I agree to hold my Esthetician/Technician and Nyah Med Spa not liable for any damages, injuries, or claims that may result from this treatment/procedure.
Printed Name:
Signature:
Date: