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CLIENT INFORMATION & MEDICAL HISTORY

PERSONAL HISTORY

Client's Name:		Today's Date:
Date of Birth:	Age:	Occupation:
Address:
City:	State:	Zip:
Home Phone:	Work Phone:	Cell Phone:
E-mail:
How were you referred to us?

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:

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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)

Cancer	Diabetes	High blood pressure
Herpes	Arthritis	Frequent cold sores
HIV/AIDS	Keloid scarring	Skin disease/Skin lesions
Seizure disorder	Hepatitis	Hormone imbalance
Thyroid imbalance	Blood clotting abnormalities	Any active infection

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)

No	Food	Latex
Aspirin	Lidocaine	Hydrocortisone
Hydroquinone or skin bleaching agents
Other:

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:

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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:

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Consent To Application of a Permanent Makeup Procedure

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:*

PROCEDURE RECEIVED TODAY

NO. OF VISITS REQUIRED

COST OF PROCEDURE(s):

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments.

1. Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon after any eyeliner procedure. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin.*

I understand

2. I fully understand this is a tattoo process and therefore not an exact science.*

I understand

3. I request the permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s).*

I understand

4. There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction. I consent (initial) or waive (initial) the patch test. If waived, I release the technician from liability if I develop an allergic reaction to the pigment.*

I understand

5. I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.*

I understand

6. I have received pre- and post-procedure instructions and I will strictly adhere to such instructions.*

I understand

7. I understand that my failure to do so may jeopardize my chances for a successful procedure.*

I understand

8. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips.*

I understand

9. I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s). I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit.*

I understand

10. I accept full responsibility for the decision to have this cosmetic tattoo work done.*

I understand

Pre-Procedure Instructions

If are a contact lens user, please wear or bring your lenses/eye glasses to all appointments.
Do not wear contact lenses during any procedure involving your eye(s).
It is recommended to have a driver available or "on-call" to drive you home following a procedure involving your eye(s).
Do not schedule an appointment prior to major events, such as a vacation, wedding, social outing, etc. as you will have to wear an aftercare ointment on your procedure site(s) for one week following the procedure(s).
If you are planning a lip color procedure and have ever experienced a cold sore, even one time in your life, it is recommended you obtain a prescribed anti-viral medication (Valtrex). The medication must be taken two days prior to the procedure. Even if you have never experienced a cold sore during your lifetime, it is recommended that you obtain an anti-viral medication (Valtrex) to be on the safe side.
It is necessary to be off of Accutane for one year, prior to all procedures. It is necessary to be off Retin A or Renova for 30 days, prior to a procedure.
Try to avoid aspirin products for 7 days prior to all procedures unless medically necessary. Tylenol is okay.
Avoid alcohol the night before all procedures.

Post-Procedure Instructions
Eyelash Enhancement, Eyeliner or Eyeshadow
Usually, eyes are most swollen the morning after the procedure as gravity takes over during the night. (Also, during the evening you may soil your pillow with residual eyeliner pigment.) However, upon waking the morning after the procedure, and with normal activity, eyes become much less swollen within a few hours. It is important to keep your eyes moist at all times with the aftercare ointment. It is best to apply the ointment approximately 2-3 times a day for 5-7 days. Use a fresh Q-tip with each application of ointment. Do not pick at the eyeliner if you notice a little lifting of color. Let it fall off naturally. Do not wear contact lenses for at least 48 hours following the procedure, however, technically, your eye doctor should advise you as to when you may resume contact lens use. Do wear sunglasses when in the sun in order to protect the fresh color for the first two weeks. Stay out of sun, pools, hot tubs and all creams around the eye for two weeks. Do not use any eye makeup for one week, and then please use a fresh tube of mascara. If there are any other concerns or questions during the healing period, call NYAH Med Spa at (678) 687-8444.

Eyebrows
Eyebrows will not appear swollen, however, they will be tender for a few days. You may also notice that the eyebrow shape will fluctuate during the first two weeks of healing. The color will be much darker initially and will also soften/lighten during the first two weeks, sometimes up to 50% lighter. You will need to apply an aftercare ointment to your eyebrows approximately 2-3 times a day for 7 days. Use a fresh Q-tip with each application. Do not wear any makeup over your eyebrows for 5 days. Do not pick at the eyebrows if you notice a little lifting of color. Let it fall off naturally. Stay out of the sun, pools, hot tubs and avoid direct water pressure. Refrain from electrolysis for at least 2 weeks following an eyebrow procedure. Eyebrows are always darker immediately after the procedure. Within the first two weeks, the color becomes much softer and more natural as it blends with your body chemistry.

Lip Liner and Full Lip Color
Lips will feel swollen and tender for a few days following the procedure. However, they will only be slightly swollen. In fact, the majority of women enjoy the fuller shape of their lips following the procedure. Although you will feel comfortable with the size of your lips following the procedure, you will question the intensity of color on your lips. Be assured that the color of your lips will lighten significantly in just a few days. It is important to apply aftercare ointment to your lips consistently during the first week, especially. You will notice that on the second day post procedure, your lips will start of slough off the pigment. Do not pick at your lips. Allow your lips to slough off the pigment naturally. Usually, by day 4 or 5 the sloughing is complete. Your lips, at that time, will be quite light in color. However, they will begin to become more colorful with each passing week up to 6 weeks. They will soften into the beautiful shade you have been patiently waiting for. Meanwhile, you may apply an ice pack (which is protected with a wet barrier film of paper toweling) for 10 minute intervals for the first couple of days. Ice may be applied every hour or so, if desired. During the first two weeks, please follow these guidelines for beautiful lip color:

Stay out of the sun (even up to 6 weeks) as the sun will quickly fade color.

Be careful when brushing your teeth as toothpaste will pull out pigment.
Consistently apply the aftercare ointment to your lips. Use a clean Q-tip with each application.
Do not pick or pull off the sloughing pigment, let it fall off naturally.
You may wear lipstick after the first two weeks if the tube of lipstick is new.
If you have any other concerns or questions, call NYAH Med Spa at (678) 687-8444.

Areola Repigmentation
Apply aftercare ointment to the pigmented areola approximately 2-3 times a day for 7 days. Starting on the second day, it is best to sleep at night without a bra so that the air can help heal the procedure site(s). Try to avoid rubbing the area and do not pick at it. Shower with the shower head to your back rather than your front.

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:

*Emergency Contact:	*Relationship:	*Telephone:

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.

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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:

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