Please read each section, check the circles to acknowledge and sign at the bottom

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

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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Microneedling Pre- and Post-Treatment Consent Form

Please read the following and initial after each statement, acknowledging your consent

PRE-TREATMENT INSTRUCTIONS:

• Discontinue use of Retin A, Retinols, Vitamin A creams and other topic medications for 3-5 days before and after your micro needling treatment.

• Sun exposure and/or usage of a tanning bed, including self-tanning products must be avoided for a minimum of 24 hours before and after the treatment, preferably 1 week. Treatment within 24 hours of prolonged sun exposure (natural sunlight, artificial tanning booth, or sunless tanning products) may result in hypopigmentation (white spots) or hyperpigmentation (dark spots) that may not clear for several months or may even be permanent. A Micro Needling treatment will not be administered on sunburned skin.

• Accutane and any other photosensitizing medication should be discontinued for a period of at least 6 months prior to receiving treatment and should not be used during your course of treatment.

• No area to be treated should receive any type of Chemical Peel for 2 weeks prior and after treatment.

• Waxing and/or use of chemical depilatories must be avoided for 2 weeks prior and after the treatment. Shaving is allowed immediately before treatment and 48-72 hours after treatment as long as there is no skin irritation.

• You may not be pregnant or lactating for this treatment.

• You may not be on blood thinners.

• You may not have active acne or open lesions on the treatment area.

• You may not have been treated for skin cancer in the desired treatment area.

• Surgical scars must be healed for 6 months prior to being micro needled.

• If you are prone to keloid scarring this treatment might not be for you. Please consult your Doctor for advice.

• Notify the provider of any tattoos, including cosmetic tattooing, in the vicinity of the area to be treated as tattoos must be avoided. That includes permanent makeup and microblading.

• If you have a history of cold sores, we may recommend you use prophylactic antiviral therapy in the form of Valtrex® or Aycylovir before your treatment. If so, follow the directions prescribed by your Doctor.

• During the course of your treatments, notify your Aesthetician of any changes to your medical history, health status, or personal activities that may be relevant to your treatment.

POST-TREATMENT INSTRUCTIONS:

• No sunscreen for 4 hours.

• No makeup for 12 hours, and make sure to use only skin care makeup until the skin has healed.

• No contact with animals/pets near the treated area, or on your hands for 4 hours.

• Make sure your sheets and pillowcases are clean, especially for the first night.

• A sunburn-like effect is normal for 1-3 days. You will look and feel sunburned after the treatment. Severity of redness will depend on how aggressive the treatment was performed. The skin may feel tight, dry, swollen, and sensitive to the touch. The treated area may appear darker and the darkened skin may flake off within 1 week. Avoid picking or exfoliating the area and allow old skin to flake off naturally.

• After Care Products and Regimen: Wash the treated area gently twice a day with a gentle cleanser. Use tepid water only. Apply a soothing, healing moisturizer or oil, as often as needed for the first 3 days.

• Sun exposure must be avoided for at least 24 hours after your treatment, preferably 1-2 weeks. If you know you will get incidental sun exposure, i.e., driving to and from work, walking from your car to the house, etc., we recommend physical avoidance of the sun in all treated areas, a protective hat and a full spectrum sun block of SPF 30 or higher.

• Do not use exfoliating medications, chemicals, or products on the treated areas for at least 1 week.

• No exercise that causes sweating, Jacuzzi, sauna, or steam baths if any skin irritation exists.

• Advil or Tylenol may be taken as necessary for discomfort. Ice packs may be used if desired to minimize swelling.

• Sleep on your back with your head elevated slightly to reduce swelling.

• For best results and efficacy, we recommend a series of 3-6 treatments administered at 2-4 week intervals. You may notice immediate as well as longer term improvements in your skin.

RF MICRONEEDLING TREATMENT | NYAH MED SPA
PRE-CARE POST-CARE INSTRUCTIONS

PRE-CARE INSTRUCTIONS:

• Do not use topical agents that may increase sensitivity of skin: retinoids, topical antibiotics, exfoliants, acids that may be drying or irritating to the skin (such as alpha hydroxyl acid (AHA), beta hydroxyl acids (BHA), exfoliating masks, salicylic acids, hydroquinone, and benzoyl peroxide acne products) 5-7 days prior.

• This treatment cannot be done when pregnant, or if you have an electronic implant (Insulin pump, pacemaker, LVAD, etc)

• Let your skincare specialist know if you have been diagnosed with cold sores or Herpes simplex.

• Do not take any anti-inflammatory medications such as ibuprofen, Motrin. Aspirin, or Advil for 5-7 days prior to treatment. These agents will interfere with the natural inflammatory process that is critical and responsible for your skin rejuvenation.

• No IPL/Laser procedures, self-tanning lotions or tanning booths, unprotected sun exposure, or sunburn for 2 weeks prior.

• No waxing, depilatory creams, or electrolysis to area being treated 5-7 days prior.

• No shaving the day of the procedure to avoid skin irritation. If there is dense hair present in the treatment area, closely shave the area the day before you arrive to your appointment. Moles, warts or actinic (solar) keratosis cannot be treated.

• Please arrive to your appointment without make-up, creams, gels, or lotions on treatment areas.

POST-CARE INSTRUCTIONS:

• A certain degree of discomfort, redness, and/or irritation during and after treatment is expected, but should not persist for more than 24 hours after treatment. After 12-hours post procedure, hydrocortisone cream may be applied 3-4 times per day to reduce redness.

• Do not take any anti-inflammatory medications such as ibuprofen, Motrin, Aspirin or Advil for 1 week. Use Tylenol only as needed for any soreness.

• Do not apply ice to your face.

• Avoid strenuous exercises that cause sweating, jacuzzi, sauna, or steam baths for 24 hours due to open pores, or up to 48 hours if inflammation exists.

• Avoid excessive heat, tanning beds, and sun exposure for a minimum of 2 weeks post treatment. If you must be in the sun, apply SPF 30 or greater, reapply every 2 hours. wear a hat, and seek shade when possible.

• Very small scabs may form 24-fl hours post treatment and may remain for several days. The scabs should not be touched or scratched (even if they itch) and should be allowed to shed naturally.

• Peeling may start 3-5 days after treatment. You will notice skin dryness and flaking. This is due to an increased turnover of skin cells. Do not pick or prematurely peel the skin, as this will cause hyper-pigmentation and/or surface scars. Allow old skin to flake off naturally and keep skin moisturized at all times.

• Use only Oxygenetix make-up post procedure or Mineral make-up after 24 hours.

• Sleep on your back with head of bed elevated to minimize swelling or pain as needed.

• Avoid surfaces that could irritate your skin such as: pillows, beards, collared or turtleneck shirts.

• Make sure you're using a clean pillowcase so dirt and oil doesn't clog pores when you sleep. The same goes for towels, or anything else that might come in direct contact with your face for an extended period of time.

• You may restart your regular skin care products and Retina once your skin is no longer irritated.

• Many clients will see continued skin Improvement for months following the last treatment.

• For best results, we recommend follow up and repeat treatments in 4-6 weeks and a series of 3-5 treatments depending on your personalized care plan.

• If you have any questions or concerns about anything whatsoever, please feel free to contact us so we can assist you.

RF MICRONEEDLING TREATMENT INFORMED CONSENT | NYAH MED SPA
(Please read and initial each statement below)

Radio-Frequency (R9 Microneedling is a procedure aimed at stimulating the body's own collagen and elastin production through micro injuries to reduce fine lines, wrinkles, stretch marks, skin laxity, skin texture, skin tone, eye-bag tones, traumatic and surgical scarring. RF Microneedling is also indicated to improve the skin tone and texture for acne and syringoma.

I, , hereby request and authorize my Esthetician/Technician with Nyah Med Spa, to preform RF Microneedling treatments for me.

I have informed my Esthetician/Technician of any contraindications that I may have concerning this treatment. Contraindications include: keloid scarring, scleroderma, history of eczema or psoriasis. history of cold sores, diabetes, vascular lesions, cardiac abnormalities/pacemaker, blood clotting problems/bleeding disorders, active bacterial or fungal infections, immune suppression, aids, HIV, hepatitis, scars less than 3-6 months old, sunburn, rashes, and/or any other chronic conditions.

I confirm that I am not pregnant or breastfeeding at this time, and that I have not taken isotretinoin (also known as Accutane) within the last 6 months. Additionally, I have not had chemotherapy or radiation treatments within the last 6 months, and I have completed a medical history checklist.

I will notify my Esthetician/Technician of any complications or concerns I may have as soon as they occur. I understand and agree that if I experience any issues or conditions due to my procedure that cause me to require medical care. I will consult a physician at my own expense.

I understand that serious complications are rare but possible. Common side effects specific to RF Microneedling include:

• Skin tightness, tingling, and stinging/sensitivity on the area being treated, for a short period of time
• Mild swelling
• Redness, and hot or warm sensation to the area being treated

I acknowledge other potential risks/side effects include:

• Infection
• Pigment changes
• Scarring
• Pain
• Persistent itching and/or redness
• Allergic reaction
• Unsatisfactory results

Results and Post-Treatment Care:

• I have been advised that though good results are expected. I am aware that RF Microneedling treatments are not permanent and natural degradation will occur over time.

• After the procedure, the treatment area(s) will be red, with mild swelling and/or bruising, and the skin may feel tight and sensitive to the touch. These symptoms should diminish within a few days following treatment, however it may rake 4 to 14 days for the symptoms to completely resolve. Redness on scar revision procedures can last longer depending on the size and depth of the area being treated.

• I understand that I must refrain from tanning in direct sunlight or in tanning beds for 14+ days following the procedure. I agree that I should not be exposed to direct sunlight, and will use sunscreen (SPF 30 or greater) for protection.

The results of this treatment may vary due to conditions such medical history, age, type/condition of skin, sun damage, damage due to smoking, climate, etc. This procedure is purely elective, and the results may vary with each individual, and multiple treatments may be necessary. The best results are achieved when the advised pre- and post-care program is followed.

I understand and agree that topical anesthetics may be used by my Esthetician/Technician for pain control during my treatments. I confirm that I have no allergies to topical anesthetic and have informed my Esthetician/Technician of any known allergies I have.

The information I have provided regarding my medical history is accurate to the best of my knowledge, and I affirm I do not have any ailments or conditions that would make this treatment/procedure incompatible with my health and wellbeing.

This service is a cosmetic treatment and no medical claims are expressed or implied.

I understand that this is a cosmetic treatment/procedure. and payment is my responsibility. This service is non-refundable.

By signing this form, I certify that I have read and fully understand the contents of this consent form; that I am at least 18 years of age, and fully competent to give my consent. I certify that The Esthetician/Technician has explained the nature of my condition, and I am fully aware that my condition is of cosmetic concern. The decision to proceed is based solely on my expressed desire to do so. I have received post procedure instructions and will strictly adhere to the given regimen. I understand the procedure risks, benefits, and alternatives. including the likely results of not preforming the procedure. The Esthetician/Technician has discussed the likelihood of major risk complications associated with this procedure including specific risks listed above and (if applicable) drug reactions. hemorrhage, infection, complications from blood or blood components. The Esthetician/Technician has also indicated that with any procedure there is always the possibility of an unexpected complication. I certify I have been given the opportunity to ask any questions I may have, and those questions have been answered. I duly authorize the Esthetician/Technician to preform PF Microneedling treatments for me, as well as any post treatment requirements that be necessary. I understand my Esthetician/Technician will take every precaution to minimize or eliminate negative reactions as much as possible, and I agree to inform my Esthetician/Technician if I experience any pain, discomfort, or sensitivities during treatment, allowing for them to make the appropriate adjustments. I agree to hold my Esthetician/Technician and Nyah Med Spa not liable for any damages, injuries, or claims that may result from this treatment/procedure.

Printed Name:
Signature:

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Date:

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: