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:

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:

BOTOX 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 have requested attempts to improve my facial expression lines with Botox® (Botulisum toxin). Injection of minute amounts diminishes frowning, crows feet, and expression lines. Botox® only treats wrinkles produced by facial muscle activity. Wrinkles present at rest may not improve. Although the results are usually dramatic, I have been informed that the practice of medicine is not an exact science and that no guarantee has been made concerning expected results. It is possible that no improvement may result, and that a larger quantity of product may have to be injected for an additional fee.*

 I Agree/Understand

2. The solution is injected with a small needle into the muscle. The benefits develop over the next 7-10 days. Typically, the injected muscle regains its action in 2-3 months and wrinkles produced by the muscle activity would then reoccur. At this point, a repeat treatment will relax the muscle and soften lines again.*

 I Agree/Understand

3. Slight swelling, and/or bruising may occur and last for several days after the injections. Rarely, an adjacent muscle may be weakened for several weeks after treatment. Among the reported rare side effects are; headache, asymmetry, twitching, numbness, temporary drooping of the eyelids or eyebrows, double vision, nausea, and flu-like symptoms.*

 I Agree/Understand

4. Alternative treatments have been discussed with the patient. I have been advised of the risks involved with such treatment, the expected benefits, and alternate options, including no treatment.*

 I Agree/Understand

5. Several sessions may be needed to complete the injection series and multiple sessions are planned.*

 I Agree/Understand

6. I am not pregnant and have no significant neurological disease.*

 I Agree/Understand

7. Botox® has been FDA approved for use in the glabellum. Use in other sites is considered “off label”. Treatment in other areas for wrinkles may be considered “innovative”. Although most of the known risks have been outlined above, there is a theoretical risk of unknown complications when a drug is used for off-label use.*

 I Agree/Understand

8. This procedure is cosmetic in nature and not covered by my insurance company. I understand that payment is my responsibility and due in full on the day of my procedure.*

 I Agree/Understand

9. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs. I have had sufficient opportunity for discussion and to ask questions.*

 I Agree/Understand
 

JUVEDERM 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. Indications: JUVÉDERM™ Ultra injectable gel are injected into areas of facial tissue where moderate to severe facial wrinkles and folds occur. It temporarily adds volume to the skin and subcutaneous tissues may give the appearance of a smoother skin surface and may help smooth moderate to severe facial wrinkles and folds. Correction is temporary; therefore, touch-up injections as well as repeat injections are usually needed to maintain optimal correction. Less material (about half the amount) is usually needed for repeat injections. Most patients need one or possibly two treatments to achieve optimal wrinkle smoothing. The results may last as long as 9 months to 1 year.*

 I Agree/Understand

2. Side Effects and Complications: Most side effects are mild or moderate in nature, and their duration is short lasting (7 days or less). The most common side effects include, but are not limited to, temporary injection-site reactions such as : redness, pain/tenderness, firmness, swelling, lumps/bumps, bruising, itching, infection and discoloration. In the first 24 hours after injection, you should avoid strenuous exercise, extensive sun or heat exposure, and alcoholic beverages. Exposure to any of the above may cause temporary redness, swelling, and/or itching at the injection sites. If there is swelling, you may need to place an ice pack over the swollen area. You should ask your physician when makeup may be applied after your treatment. Be sure to report any redness and/or visible swelling that lasts for more than a few days, or any other symptoms that cause you concern.*

 I Agree/Understand

3. Contraindications: JUVÉDERM™ Ultra injectable gel should not be used if you have: • Severe allergies marked by a history of anaphylaxis or history or presence of multiple severe allergies • A history of allergies to Gram-positive bacterial proteins.*

 I Agree/Understand

4. The following are important treatment considerations for you to discuss with us and understand in order to help avoid unsatisfactory results and complications: • Please inform us prior to treatment: If you are using substances that can prolong bleeding, such as aspirin results and complications: • Please inform us prior to treatment: If you are using substances that can prolong bleeding, such as aspirin or ibuprofen, as with any injection, may experience increased bruising or bleeding at the injection site. • Please inform us prior to treatment: If you are on immunosuppressive or therapy used to decrease the body’s immune response, as there may be an increased risk of infection • Please inform us prior to treatment: If you are pregnant or breastfeeding, • Please inform us prior to treatment: If you have history of excessive scarring (eg, hypertrophic scarring and keloid formations) and pigmentation disorders.*

 I Agree/Understand

5. If laser treatment, chemical peeling, or any other procedure based on active dermal response is considered after treatment with JUVÉDERM™ Ultra injectable gel, there is a possible risk of an inflammatory reaction at the treatment site.*

 I Agree/Understand

6. The safety and effectiveness of JUVÉDERM™ Ultra injectable gel for the treatment of areas other than facial wrinkles and folds (such as lips) have not been established in controlled clinical studies. PATIENT’S ACCEPTANCE OF RISKS.*

 I Agree/Understand

7. I have read the above information and have discussed it with my physician. I understand that it is impossible to be informed of every possible complication that may occur. No guarantees about results have been made. By signing below, I agree that my doctor has answered all of my questions and that I understand and accept the risks, benefits, and alternatives of JUVÉDERM™ Ultra.*

 I Agree/Understand
 

BOTOX* Cosmetic (Neurotoxin BoNTA) and Dermal Fillers (Juvederm®)
Educational Material and Consent Form.

Patient Name: 

YOUR HEALTH ISSUE/INDICATION:

You have facial wrinkles related to muscle contraction and/or areas of volume loss where volume restoration is desired, and accordingly, you are asking your doctor and provider/trainee to give you rejuvenation with BOTOX® Cosmetic (Neurotoxin "BoNTA") and/or treatment with Juvederm® Ultra XC or Juvederm® Ultra Plus XC, Voluma®, Volbella® or Vollure®, (collectively Juvederm®") (Hyaluronic Acid Dermal Filler).

The BOTOX® AND JUVEDERM® PROCEDURES:

BOTOX® Cosmetic ("BoNTA"): Approved by the Food and Drug Administration (FDA) for wrinkle reduction in the glabellar (between the eye brows) region, forehead, and eye region (crow's feet). It works best on frown lines caused by muscles used during squinting or frowning. The treatment plan includes an injection of an ap¬propriate amount of BoNTA, a purified Neurotoxin produced by the Clostridium Botulinum bacteria, into a targeted facial muscle to intentionally produce weakness or temporary paralysis of the injected muscle. Relax¬ation of the muscle should improve lines and wrinkles that the targeted muscle action produced or should im¬prove contour of the face. Response is usually seen within 7 to 10 days after injection. Lines and wrinkles present when the face is at rest may not improve with treatment of BoNTA alone since BoNTA is designed to treat lines caused by facial muscle action.

It may take up to 7 days for the effects of BoNTA to be noticeable. The results will last for 3 to 6 months. This treatment is temporary. It is common for the muscle's action, along with its associated wrinkles, to return within 3 to 6 months. Repeat injections are necessary to maintain the effects achieved and can be performed 14 days after any previous injections.

Juvederm®: Approved by the FDA to address lines and/or wrinkles and/or volume loss in certain approved sites of moderate to severe facial wrinkles and folds (such as naso-labial folds) and cheek and lip volume loss. Juvederm® may also address mental crease, marionette lines and/or other "off-label" areas (see below). If your provider is injecting Juvederm®, a topical anesthetic may be applied before the injection and a cool pack may be placed on the face after the procedure to reduce pain and swelling.

BoNTA and Juvederm®: If you undergo BoNTA shots and/or Juvederm® fillers in areas of your face not specifically approved by the FDA, then you are receiving a treatment which is "off-label." This means that your provider is using BoNTA and/or Juvederm® in a way that is not specifically approved by the FDA. The lack of FDA approval does not mean that it is not safe or that it will not work for you.

 (initials)

DISCLAIMER OF GUARANTEES AND EXPLANATION OF MATERIAL RISKS:

The practice of medicine is not an exact science and no guarantees or assurances have been made concerning the outcome and/or the result of these procedures. I understand that the providers at The Injectable Academy.

LLC may apply topical anesthetic to the area planned for treatment with Juvederm®. I understand if I have an allergy to the anesthetic, I may develop a rash, itching, mild swelling and though rare, cardiac symptoms such as chest pain, shortness of breath, myocardial infarction (heart attack) or abnormal heart rhythm that could lead to disability or death. I agree to advise my treating clinician of any known allergies to anesthetics. The practical alternatives to application of such is to have the injection performed without any anesthesia/topical numbing.

BOTOX® Cosmetic ("BoNTA") Injections: Injections with BoNTA are routinely performed without incident. However, there are some material risks. It is not possible to list every risk for this procedure and this consent form only attempts to identify the most common material risks which are headache, bruising, poor cosmetic result, pain during injection, numbness, asymmetry, twitching, drooping of the eyelids or eyebrows, infection, and flu-like symptoms. Bacterial or viral infections may occur at the injection site. Fewer facial expressions will be possible after an injection with BoNTA. Long term effects are unknown. For unknown reasons, some patients may not respond to the injection of BoNTA.

Juvederm®: Should not be used by patients (a) with severe allergies or with a history of anaphylaxis to Juvederm®; (b) who are pregnant or nursing; (c) who are under the age of 21; or (d) who are on immunosuppressive therapy. Juvederm® should not be used in areas of active infection. Patients using substances that reduce co¬agulation, such as blood thinners, aspirin and non-steroidal anti-inflammatory medicines may experience in¬creased bleeding with resulting bruising at the injection sites.

Other risks may include temporary local pain, redness, and itching, skin discoloration, bruising and swelling of the treated areas. Additional risks may include poor cosmetic result, extrusion, infection, asymmetry, folds or areas of depression, need for possible further correction, nodule formation, allergic reaction, firm hard areas on folds, or lines, and/or inadequate correction. Bacterial or viral infections at the site of injection are rare but may occur.

As with any injection into the head or neck, the injected material may be inadvertently implanted in a blood vessel, which could cause occlusion, infarction, or embolic phenomena. If this were to occur, I understand that my doctor and provider/trainee would (i) inject hyaluronidase, a substance designed to dissolve the clot and relieve the symptoms and signs of occlusion, and/or (ii) apply nitroglycerin paste topically in an attempt to dissolve the clot and increase blood flow to the area and/or (iii) provide an aspirin for me to take to assist in dissolving the clot. I understand there are no guaranteed results with this and permanent cosmetic and medical issues may result.

Injections into an area where there is a history of herpes simplex may result in an outbreak of symptoms. Ad-ditional side effects are possible, but none have been observed or are known of at this time. I am advised of the possibility and nature of complications which cannot be accurately anticipated and therefore, there can be no guarantee as expressed or implied either as to the success or other result of treatment. If laser treatment, chemical peel or any other procedure based on active dermal response is considered within several days post treatment, there is a possible risk of eliciting an inflammatory reaction at the implant site. Long term effects are unknown.

 (initials)

OTHER CHOICES/ALTERNATIVES TO TREATMENT:

BOTOX® Cosmetic ("BoNTA"): If you choose not to undergo BoNTA, then you may choose other options. You could treat frown lines with:

Dennabrasion, Chemical Peel, Laser Resurfacing, Dermal Filler Injection, Face Lift, Brow Lift, and/or Other Surgical or Topical Skin Treatments.

Juvederm®: If you choose not to undergo Juvederm®, then you may consult with a plastic surgeon for addition¬al options.

Your provider will let you know what other choices may be best for you. The degree of success of other treatment options will depend on your specific health condition.

ADDITIONAL FACTS:

BOTOX® Cosmetic ("BoNTA"): Contains human albumin. Albumin is a protein in the blood which is made by the liver. If you have BoNTA injections, there is a possibility you could develop Creutzfeldt-Jakob Disease (brain damage that causes death within a few months to years) or another viral disease. The risk of such disease development is very low. There has never been a reported case of Creutzfeld-Jakob Disease or other viral disease due to human albumin.

Patients with certain muscle or nerve diseases should not receive BoNTA injections. You should talk to your doctor and provider/trainee about your health history before you receive BoNTA injections.

Some drugs, vitamins, and herbs can make BoNTA stronger which may cause bleeding and bruising. You must tell your doctor and provider/trainee about all of the drugs, vitamins, and herbs you are taking. You should not undergo BoNTA injections if you are pregnant or breastfeeding.

You may not lie down for four (4) hours or workout for 24 hours after you have BoNTA shots. If you think you are experiencing effects from the toxin, then you should not drive a car or operate any equipment or machinery. The manufacturer of this product states that BoNTA is not the same as other botulinum products.

Juvederm®: Contains lidocaine and are gels of hyaluronic acid generated by non-animal protein. According to the manufacturer, Allergan®, there is no necessity for skin testing prior to receiving treatment, as an allergic reaction is very unlikely. Juvederm® has been shown to provide correction to the injected sites for up to a year; Voluma® up to two years; Vollure® up to 18 months; and Volbella® up to 12 months. Without touch-up injections, the correction will subside gradually and your skin and/or cheeks will look as it did before treatment.

CONSENT TO TREATMENT:

I understand that the registered nurse, Angela Austin, at NYAH Med spa will rely on my documented medical history, as well as other information obtained from me in determining whether to perform the below indicated procedure(s). I agree to provide accurate and complete information about my medical history and conditions. I herein state that I am not pregnant, nursing, or have any known neurological diseases. I do not have any severe allergies or area of active infection, and I am at least 18 years old (for BOTOX®) and 21 years old for (Juvederm®). If I am taking aminoglycoside antibiotics, Penicillin, or Quinine, I understand these medications may increase the effect of Botox and Juvederm® fillers.

I understand all the facts provided to me in this form. I give my consent to Dr. Mark Hogan and the provider at Nyah Medspa, Angela Austin, RN to give me Botox  or Juvederm. By signing below, I agree that my doctor and provider RN Angela Austin have discussed all of the facts in this form with me, and no one has given me a guarantee about success or outcome. I have had a chance to ask questions, and all of my questions have been answered.

PHOTOGRAPHS: I give permission for photographs to be taken which will be used for documentation in my medical record. I also give permission for these photographs to be used for illustrations for scientific papers or use in educational/training lectures. I understand my name shall not be used in any publication.

FOLLOW UP TREATMENT: I agree to follow up with the doctor at Nyah MedSpa if instructed. I also agree to advise Angela Austin, RN of any changesin my condition or any problem I may experience.

I understand that my consent is indefinite unless/until otherwise revoked by me in writing.

BOTOX*Cosmetic ("BoNTA") and Juvederm®:

This form outlined and explained to you the risks, alternative options, likely results, and possible issues that could occur with treatment of BOTOX® Cosmetic ("BoNTA") and Juvederm®. After you have read and re-viewed this form with your doctor and provider/trainee, if you do not believe that you fully understand the risks, alternative options, likely results, and possible issues of BOTOX® Cosmetic ("BoNTA") and Juvederm® treatment, do not sign this form until all your questions have been answered.

Date: 
Name of Patient: [Please print name] 
Signature of /Patient:

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: