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.
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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)
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.
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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.
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INFORMED CONSENT FOR NEUROTOXIN INJECTION (BOTULINUM TOXIN TYPE-A AS NEUROTOXINS, DYSPORT, JEUVEAU, AND XEOMIN) between the patient and [Angela Smith Austin/ Nyah Med Spa] FOR THE TEMPORARY TREATMENT OF SUPERFICIAL FACIAL WRINKLES
My signature and initials after each statement below constitutes my acknowledgment that:
Neurotoxin Injections work by paralyzing nerves and muscles.
1. I, , consent to and authorize Angela Smith Austin of Nyah to perform a treatment of facial wrinkles with Neurotoxins.
2. The nature and purpose, possible benefits and risks of the treatment have been explained to me, and questions I have regarding the treatment have been answered, to my satisfaction and I accept them and consent to receive the treatment. I agree that I have been given an opportunity to ask questions before I sign and my questions have been answered to my satisfaction, and I have been told that I can ask other questions at any time.
3. I understand surgery, medications, no treatment, or other treatment alternatives may be as effective or more effective in reducing the appearance of wrinkles. Risks and potential complications are associated with alternative forms of medical or surgical treatment. Other options not mentioned here may exist.
4. I am fully aware of the risks of complications or injuries that can occur from this treatment, both from known and unknown causes, and I freely assume those risks. I understand that the treatment is not an exact science, and I acknowledge that no guarantees have been made to me concerning the results or outcome of the treatment.
I understand that the known complications could include, without limitation:
• Redness, swelling/edema, itching, pain or pressure lasting more than one week
• Nodules or induration at the injection site
• Discoloration of the injection site
• Poor effect
• Allergic reactions
• Bruising
• Facial asymmetry
• Paralysis leading to droopy eyelid and double vision
• Some patients may experience weakness or flu-like symptoms
• Visual problems
• Dry Eyes
• Some patients may develop antibodies to Neurotoxins
• Post treatment bacterial, viral and/or fungal infection requiring further treatments
• Facial asymmetry (one side looks different than the other)
• Paralysis of a nearby muscle leading to: droopy eyelid (in approximately 1-2% of injections, this usually lasts 2-3 weeks), double vision, inability to close eye, dry eye, difficulty whistling or drinking from a straw
• Loss of vision, this is extremely rare, however, it can be caused by internal bleeding around the eyeball or needle stick injury5. 6. 7. 8. 9. 10. 11.
• Permanent loss of muscle tone with repeated injection
• Occasional numbness of the forehead lasting up to 2-3 weeks
I also certify that I have none of the known conditions that would contraindicate treatment. These conditions include hypertrophy scars, a history of any autoimmune disease, immune therapy, any significant neurological disease (including but not limited to: Eaton-Lambert syndrome, amyotrophic lateral sclerosis (ALS), or myasthenia gravis, an infection, skin condition, or muscle weakness at the site of the injection, pregnancy or nursing. I am not pregnant, breast-feeding, and I have no known allergy to Neurotoxin Injections such as Neurotoxins/Dysport/ Jeauveau/Xeomin or the toxin ingredients (including lactose, sucrose, saline) to human albumin or to eggs.
There are many medications and injectable fillers that are approved for specific use by the FDA, but some proposed uses may be “Off-Label”, that is, not specifically approved by the FDA. Neurotoxin Injections such as the products listed are FDA approved for use on the forehead lines, glabellar lines, and crow’s feet. The above medication has not been approved by the FDA for any use other than as described above. This could mean that they may not meet FDA approval requirements for safety, effectiveness, and quality. However, it could also mean that the manufacturer has not yet applied for FDA approval. By initialing and signing this consent, I acknowledge that I have been informed about the lack of FDA approval for anything other than the above purposes relating to the medication discussed in this paragraph and I understand and accept that the risks and wish to receive the medication(s).
I certify that I have read this entire informed consent and that I understand and agree to the information stated in this form. I certify that I am a competent adult of at least 18 years of age, or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian will also be required before treatment. This informed consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I agree that any picture taken of my treatment site may be used for publication and teaching purposes, however, my name will not be disclosed and complete confidentiality of my name will be maintained.
No guarantee, warranty or assurance has been made as to the treatment results. I acknowledge that I may be disappointed with the results of the procedure. The procedure may result in unacceptable visible deformities, loss of function and/or loss of sensation. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.
I will hold [Nyah Med Spa] and its owner[s], agents, employees and shareholders completely harmless from all and any litigation or claims made should I have any adverse reaction to Neurotoxins/ Jeauveau/ Dysport/ Xeomin or reaction to these products..
Further, I hold all providers completely harmless from any and all litigation, malpractice suits or claims made in relation to my receiving Neorotoxin Injections. Any and all complications should be seen in the emergency room or by your local physician.. [Nyah Med Spa] providers and its employees maintain the right, under all circumstances and without penalty, to not perform the procedure should such decision be made by them.
If you are planning a LASIK® procedure, please inform the provider as your Neurotoxin Injections may be deferred. I am aware that when small amounts of purified Neurotoxins are injected into a muscle it causes weakness or paralysis of the muscle. This appears in 3-14 days and usually last 3-4 months but can be shorter or longer. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. I understand that I will not be able to “frown” while the injection is effective but that this will reverse after a period of months at which time re-treatment is appropriate. I understand that the results are of temporary nature, and more treatments will be needed to maintain improvement. I agree to adhere to all safety precautions described here including:
• No laying down or reclining for four hours after injection
• No scratching or rubbing the injected area
• No bending forward for four hours• Make up should be avoided for one to two hours after injection
This agreement is non-transferable and may not be altered by anyone without the express written consent of [Nyah Med Spa]. Further, this agreement does not expire.
12. I agree to pay AngelaSmith Austin/ Nyah Med Spa for the above-mentioned services.
My signature below evidences my voluntary agreement to receive this treatment from Angela Smith AustiRN/ Nyah Med Spa,, and that I am the patient or am authorized to act on behalf of the patient to sign this consent form. By signing below, I agree that I have read, understand, and agree to all of the statements contained in this consent form.
I understand that my agreement is effective on the date signed below and that I may revoke my agreement in writing. My revocation will not be effective for actions already taken by the Practice or that are in progress and will only be prospectively effective.
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INFORMED CONSENT FOR DERMAL FILLER TREATMENT
The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.
THE TREATMENT
Treatment with dermal fillers (such as Juvederm, Restylane, Radiesse and others) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under the skin with a very fine needle. This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out. The results can often be seen immediately.
Initial
RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: 1) Post treatment discomfort, swelling, redness, bruising, and discoloration; 2) Post treatment infection associated with any transcutaneous injection; 3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patches; 6) Granuloma formation; 7) Localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs.
Initial
PREGNANCY AND ALLERGIES
I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving dermal fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine.
ALTERNATIVE PROCEDURES
Alternatives to the procedures and options that I have volunteered for have been fully explained to me.
Initial
PAYMENT
I understand that this is an "elective” procedure and that payment is my responsibility and is expected at the time of treatment.
Initial
RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue treatment at any time.
Initial
TRAINING COURSE
I understand that I have volunteered to be a model patient in a training course and the doctor/healthcare professionalwho will be treating me has had limited experience with the method of treatment.
Initial
I hereby indemnify Nyah Med Spa from any liability relating to the procedures that I have volunteered for. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician.
Initial
I hereby indemnify the facility/meeting room/hotel where this treatment is being performed from any liability relating to the procedures that I have volunteered for.
Initial
PUBLICITY MATERIALS
I authorize the taking of clinical photographs and videos and their use for scientific and marketing purposes both in publications and presentations. During courses given by Common Sense Dentistry and/or The American Academy of Facial Esthetics (AAFE), I understand that photographs and video may be taken of me for educational and marketing purposes. I hold the AAFE harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.
Initial
RESULTS
Dermal fillers have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. Its effect can last up to 6 months. Most patients are pleased with the results of dermal fillers use. However, like any esthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatment to achieve the results you seek. The dermal filler procedure is temporary and additional treatments will be required periodically, generally within 4-6 months, involving additional injections for the effect to continue. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue conditions, my general health and life style conditions, and sun exposure. The correction, depending on these factors, may last up to 6 months and in some cases shorter and some cases longer. I have been instructed in and understand the post-treatment instructions.
Initial
I understand this is an elective procedure and I hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation, lip enhancement, establish proper lip and smile lines, and replacing facial volume. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English.
Patient Name (Print)
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Consent for Treatment with Hyaluronidase
Hyaluronic acid (HA) fillers are sterile gels consisting of non-animal stabilized hyaluronic acid for injection into the skin to correct facial lines, wrinkles and folds, for lip enhancement and for shaping facial contours.
Occasionally these fillers need to be dissolved when the aesthetic treatment has not produced the desired outcome or there is a possibility of vascular occlusion or impending necrosis (tissue death) which could lead to compromise of healthy tissue.
Hyaluronidase is an enzyme which breaks down hyaluronic acid fillers, but it can also break down naturally occurring hyaluronic acid present in the body, the results can be unpredictable.
I understand that there will be loss of volume and there can be some skin laxity which in itself may not provide a good aesthetic result. Although some of the effects can be immediate, I understand it can take up to 24-48 hours for results to be seen and the treatment may need to be repeated.
What are the possible side effects of hyaluronidase?
Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Less serious side effects may include pain, itching, redness, or swelling where the medication was injected. This is not a complete list of side effects and others may occur as my provider today has discussed with me.
I have disclosed all my medical history and medications to my provider. I am currently not taking any of the following medications.
1) Furosemide (Lasix)
2) Phenytoin (Dilantin)
3) A sedative or anxiety medication (such as Valium, Xanax)
4) Aspirin or salicylates
5) Cortisone or ACTH (Corticotropin)
6) Estrogens
7) An antihistamine (such as a cold or allergy medicine)
The use of and the indications for the administration of hyaluronidase have been explained to me by my practitioner and I have had the opportunity to have all questions answered to my satisfaction.
After the treatment some other common injection-related reactions might occur. These reaction may include redness, swelling, pain, itching, bruising and tenderness at the injection site.
They have generally been described as mild to moderate and typically resolve spontaneously a few days after injection.
I acknowledge that I will have to remain at the clinic for thirty minutes after the procedure so that I can be observed by the practitioner and that I may need to return to the clinic in 1-2 weeks after treatment to assess if further hyaluronidase is to be administered.
I have answered the questions regarding my medical history to the best of my knowledge. I have also received the aftercare information and its contents have been explained to me and I will follow the advice given.
I consent to the administration of hyaluronidase. I am satisfied with the explanation. If I have any questions or problems after treatment I will call my medical provider who performed my service today.
Patient Signature
Treatment Instructions
NEUROTOXIN & FILLER PRE TREATMENT INSTRUCTIONS
2 WEEKS BEFORE INJECTIONS
• Foods and Medications to Avoid. Two weeks before your appointment try to avoid nuts, seeds, fish, fish oil, NSAIDs, supplements, and anything that prolongs bleeding. This will significantly help minimize bruising, bleeding and swelling.
• Arnica Supplements. You can start Arnica supplements a week prior to injection to help with post injection bruises. Arnica helps to speed up the fading away of bruises.
• Medication and Supplements: Talk to your primary care doctor or physician specialist. If you are on blood thinners you may need to stop these a few days to weeks prior to your treatment. Speak to your prescribing physician regarding safety of stopping and restarting these medications. We do not recommend patients that are on life saving medications stop their medications in order to have any cosmetic procedures performed.
• Prevention of Cold Sores: Patients prone to cold sores may need to start a prophylaxis dose of an anti-viral medication prior to their injection treatment. Your physician provider will prescribe this medication prior to your treatment if they feel it is necessary.
DAY OF INJECTIONS
• Eat and drink before your treatment. It is not uncommon for patients to “pass-out” or get lightheaded during their injection. Having a good blood sugar and being hydrated will make it less likely that you will feel queasy during your treatment.
• Minimize make up and lotions. Minimize make-up, in and around areas where you would like to get injections performed. Our medical assistants will remove your make-up prior to treatment. You can bring make-up with you to apply immediately after your treatment.
• 20 – 30 minutes of topical numbing recommended for fillers. We recommend numbing cream application prior to dermal injections. The numbing cream needs a good 20 – 30 minutes to exert its full effect, hence we ask all our filler injection patients to come a little earlier to allow for the numbing time.
NEUROTOXINS & FILLER POST TREATMENT INSTRUCTIONS
After your filler injection it is normal to have some swelling, pinpoint bleeding and bruising. If numbing cream was applied for your procedure you will still feel numb for another 1-2 hours after your procedure. Please be sure to follow our post procedure instructions in order to minimize swelling, bruising and decrease downtime.
• Ice. Use a small bag of frozen peas in a sandwich bag or crushed ice to gently ice the area. No heavy ice bags. Ice for 20 minutes on and 20 minutes off. Continue the icing for 48 hours if possible for filler injections.
• Minimize Strenuous Exercise. We recommend no strenuous exercise for 48 hours in order to reduce swelling and bruising from filler injections.
• Do not manipulate or massage or rub or poke the area. Unless specifically advised by your physician, do not massage or manipulate your face. For one week avoid facials or rough scrubbing of the face. You can wash your face gently.
• Use make-up and concealer to cover up bruises. You can use makeup and concealer the day of your injections to cover up any bruising.
• Non-surgical rhinoplasty patients should avoid glasses if they “dig into” the injection region. Bring your glasses to your appointment to show Dr. Shervin Naderi if they would be appropriate to wear after non-surgical rhinoplasty. Additionally, if you are an avid swimmer mention the use of swim goggles during your consultation.
• Eat pineapples and drink pineapple juice. Pineapples have a natural anti-inflammatory property to them that helps minimize swelling after injections.
• Do not over-evaluate your face the first two weeks. The first two weeks after injections it is normal to have bruises, swelling and asymmetry. We recommend waiting two weeks for swelling and bruising to be completely gone before you can appreciate your final results.
• Take Tylenol for Pain. It is normal to experience some pain and sensitivity in the injection area. Most patients find that Tylenol can help relieve this post-injection pain. Avoid NSAIDs such as Motrin and ibuprofen as these can make swelling and bruising worse.
WHAT TO EXPECT
• Neurotoxins/Dysport® Effects. Neurotoxins/Dysport® take up to 2 weeks to fully work. You may start to notice the effect as soon as 3 days but do not be surprised if you have to wait the full 2 weeks. Neurotoxins/Dysport® wear off in 3-4 months on average and must be repeated 3-4 times a year.
• Bruising. Bruises may last 1-2 weeks. Bruises can show up several days after the treatment. Bruising can be covered with full coverage concealers. Tear troughs and lips are more likely to bruise because these areas are more vascular than other parts of the face.
• Swelling. Swelling may not always be even from side to side depending on pre-existing facial asymmetry, volume of filler injection and bleeding at each injection site. Initial swelling takes 2 weeks to settle. Sleeping propped up and icing can minimize this side effect. Avoid exercise first 48 hours or longer as swelling increases when working out. Do not manipulate or massage area as this can aggravate swelling
• Asymmetry. Asymmetry can be related to swelling. We advise waiting 2 weeks to see if asymmetries are due to swelling or from filler. Please keep in mind that once you start to analyze your face it is not rare to “notice” new asymmetries that have been there your entire life.
• Lumps and Bumps. Filler will feel firmer than your own tissue. Do not massage or manipulate the area. The feeling of lumps and bumps will usually improve within 2 weeks.
• Subtle Results. A 1 cc syringe of filler is the equivalent of 1/5th of a teaspoon in volume. After swelling subsides there may be a need for additional filler injections if you desire increased volume. Our doctors are very conservative and do not over inject patients. Our physicians prefer to add volume slowly with time to achieve. The first time getting injections the results tend to go away faster. With repeat treatments results last longer as you build your own collagen around the injection sites.
• Dry Lips. Lips will also be more dry post injections. Ice the areas and keep lips lubricated with Vaseline or Aquaphor. No more than 20 minutes of ice at a time
WHEN TO CONTACT US
Please notify our office immediately if you feel that you may be experiencing any of these possible complications after your filler injections:
• Hypersensitivity or allergic reactions
• Cold sore or herpes simplex virus outbreak
• Acne breakout
• Changes in skin sensation or ability to move parts of the face
• Signs of infection: fever, redness and
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: