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:

WEIGHT LOSS INJECTIONS INTAKE FORM
ALL INFORMATION IS CONFIDENTIAL

How did you hear about us? 

What are your main weight issues and goal?


Are you currently on any weight loss programs or special diet?    Yes      No
If Yes, please explain:


Do you smoke?    Yes      No
If Yes, how many per day: 

Do you consume alcohol?    Yes      No
If Yes, what is your weekly consumption? 

Do you take any medication, birth control, vitamins, mineral or herbal supplements?
 Yes      No
If Yes, please list all medications:


Do you exercise regularly?    Yes      No
If Yes, please specify:


Do you have any type of injury or have you had any type of operation in the last 12 months?
 Yes      No
If Yes, please specify:


Do you have any Allergies    Yes      No
If Yes, please list all allergies and/or reactions to drugs, food, latex, etc.:

 

Please list all Surgeries and other Hospitalizations:

Do you currently have or have you had any of the following Health Conditions (Check all that apply):

Are you currently under the care of a Physician?    Yes      No
If Yes, please list name of Dr. and Contact Info:


Have you ever had weight loss surgery?    Yes      No
If Yes, date of procedure: 
If yes to above, Highest Pre-Surgery Weight: 
Lowest Post Surgery Weight: 

What do you feel are the main contributors to having excess weight? (Check all that apply):

What foods do you crave most often and how often do you eat these foods?


What methods have you used in the past for weight loss?
 Exercise     Diet Modifications      Prescription Medications      Weight Loss Pills
 Therapy Injections
Please list details of items marked above:


Do you experience any potential weight loss obstacles below?
 Skipping Meals      Binge Eating       Stress Eating
Psychological Factors      Unsupportive Partner      None
Please specify if you marked any of the above items:


How long has your weight been an issue? 
What is your ideal weight? 
What is your heaviest weight? 

Are you currently at your heaviest weight?    Yes      No
If Yes, for how long? 

I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the practitioner or other health professional of my current medical health conditions and to update this history. A current medical history is essential for the practitioner to execute appropriate treatment procedures, I have read and understand the above medical history questionnaire. I acknowledge that all answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form.

Client Name: 
Client Signature:

Date:

Weight Management Prescription Drug Management Consent for Semaglutide and Tirzepatide

This document is intended to serve as a confirmation of informed consent for compounded semaglutide and Tirzepatide, which is a prescription weight management medication.

Semaglutide is a glucagon-like peptide 1 receptor receptor substance that reduces appetite so the user minimizes their food intake. Branded names for this are known as Ozempic and Wegovy.

Tirzepatide is a dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor substance that regulates blood sugar levels and stimulates weight loss. Tirzepatide works by controlling blood sugar and slowing down digestion; this causes the user to feel full faster. Branded names for this are known as Mounjaro.

A. Patient Informed Consent

1. I voluntarily request that Dr Fara Movargharnia treats my medical condition.
2. I have informed my provider of any known allergies, my medical conditions, medications, social/family history.
3. I have the right to be informed of any alternative options, side effects, and the risks and benefits.
4. I understand the mechanism of action of the medication.
5. I understand how it is to be administered.
6. I understand the prescription will come from a compounding pharmacy, which is not FDA approved. I have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself.
7. Prices may vary and change depending on promotions and dosage amounts.
8. Dr. Fara Movagharnia may change the pharmacy based on several factors (availability, shipping time, cost). Dr. Fara will tell you as this happens.
9. It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider.
10. I understand this medication may cause adverse side effects (see below). I understand this list is not complete and it describes the most common side effects, and that death is also a possibility of taking this medication. I understand symptoms may be worse after there has been a change in my medication dose or when first starting the medication.

Common side effects include, but are not limited to:

● Gastrointestinal: Nausea/vomiting, abdominal pain, upset stomach, heartburn, burping, gas, mild to excessive bloating, loss of appetite, stomach flu symptoms, diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis, GERD, gastritis, lipase increase, amylase increase, acid reflux
● Neurological: Headache, dizziness, tiredness, anxiety, chills, cold sweats, depression, recurrent fever
● Cardiac: Heart rate increase, Hypotension, shortness of breath, irregular heart beat, difficulty breathing
● Endocrine: Fatigue, hypoglycemia (diabetic patients), alopecia
● Ophthalmic: Retinal disorder (diabetic patients) , yellowing of eyes or skin, vision changes
● Skin: redness or pain at injection site, skin itching, rash, redness
● Low blood sugar
● Hair loss

Serious Reactions include, but are not limited to:
● Thyroid C-cell tumor (animal studies)
● Thyroid Cancer
● Medullary thyroid cancer
● Hypersensitivity reaction
● Anaphylaxis
● Angioedema
● Acute kidney injury
● Kidney failure
● Chronic renal failure exacerbation
● Gallbladder problems, gallbladder disease
● Pancreatitis
● Cholelithiasis
● Cholecystitis
● Syncope
● Allergic reactions
● Swelling of the face, throat or tongue
● Difficulty breathing or swallowing

B. I understand that I have the following responsibilities:

1. I agree to obtain prescriptions for compounded semaglutide / Tirzepatide only from Dr. Fara Movagharnia with Nyah Med Spa.

a. If I am looking to transition to a non-compounding pharmacy or seek insurance coverage, I will tell Dr Fara in advance.

2. Medical history: I will tell Dr. Fara my complete medical history, including: allergies, medications, medical/surgical/social/family history.

a. Dr. Fara may ask to review, with your permission, your medical history (medications, recent lab results, pertinent imaging results).
b. I understand that if I become pregnant or start trying for pregnancy, I must stop this medication.
c. I will be honest to the best of my ability the history she needs to know.
d. I will tell my provider any updated health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).
e. My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider
f. I will always tell other providers about all medications I am taking.
g. Dr. Fara may ask for me to seek additional labs while on treatment to ensure it’s safety.

3. Directions for use: I will take my medications only as prescribed according to the directions, led by Dr. Fara Movagharnia..

a. If I feel my medications are not effective, or are causing undesirable side effects, I will contact my provider for instructions.
b. I will not adjust my medications without prior instruction to do so.
c. I understand that the medication must be either kept frozen or refrigerated.
d. I understand this medication must be self-injected in the subcutaneous tissue once weekly. I will not inject any less than 7 days unless directed by Dr. Fara (example: travel).
e. I will not share needles and dispose of needles safely.
f. If I’m having troubles with the administration of the medication, I will seek help from Dr. Fara Movagharnia.
g. The medication expires after 12 weeks. I will refer to the Beyond Usage Date (BUD).

4. Refills:

a. All refills will require an appointment.
b. I understand, I may need to schedule refill appointments ahead of time to avoid delays in refills.
c. Refills will get ordered Monday.
d. I will not ask for early refills.
e. I understand that I may be asked to bring the medication with me to my appointments to check the quantity left or asses how I am injecting.

5. Safety:

a. I understand it is important to keep my medication away from children (<18 years old)
b. I am the only one who will use my medication. I will not give or sell my medication to anyone else.

6. If Dr. Fara deems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply.

C. Discontinuation of medication: I understand that Dr. Fara may stop prescribing my medications if:

a. I am having unfavorable side effects or it’s not working to treat my medical condition
b. I have been untruthful in my medical or family history
c. I do not follow through with the recommended plan of care set by Dr. Fara Movagharnia.
d. I do not follow any parts of “Part B: responsibilities” in this agreement.

While using Semaglutide or Tirzepatide, it is highly recommended that you:
• Eat a fibrous diet. Focus on fruits and vegetables that are high in fiber.
• Eat small high protein meals as digestion is slowed down while on this medication.
• Avoid foods high in fat as they take longer to digest.
• Limit alcohol intake as this medication can lower blood sugar.
• Drink at least 32 oz of water per day to avoid constipation.

Do not take this medication if:
• You have a personal or family history of medullary thyroid carcinoma (Thyroid Cancer)
• Multiple Endocrine Neoplasia Syndrome type 2
• You are pregnant or plan to become pregnant while taking this medication.
• You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist.
• Specifically, if you are prescribed insulin – because the combination may increase your risk of hypoglycemia (low blood sugar).
• You have a history of Pancreatitis.
• You are allergic to Semaglutide,Tirzepatide, BPC-157, or any other GLP-1 Agonist such as Ozempic, Wegovy, Adiyxin, Byetta, Bydurteon, Rybelsus, Trulicity, Victoza.
• If you have other allergies. This product many contain inactive ingredients, which can cause allergic reactions, which can cause allergic reactions or other problems. Talk to your pharmacist for more details. Before using this medication, tell your doctor your medical history.

Possible drug interactions: Anti-diabetic agents, specifically: Insulin and Sulfonylureas (i.e., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other agonist medicines such as: Ozempic, Wegovy, Adiyxin, Byetta, Bydurteon, Rybelsus, Trulicity, Victoza (THIS MAY NOT BE AN ALL-INCLUSIVE LIST). Other medications used in diabetes, please tell your provider about any medications that may lower your blood sugar.
Possible side effects: Nausea, diarrhea, vomiting,

Semaglutide / Tirzepatide protocol:

● Every 30 days you must request a refill and self-report: current weight, blood pressure, concerns regarding treatment, change in other prescribed medications, change in medical history, change in desired weight loss outcome.
● The most efficient method to request a refill is through calling the office to book an appointment.
● It can take 7-10 business days to receive some forms of semaglutide. Please be mindful of self-reporting in a timely manner to not delay your administration.
● We do offer in office visits and assistance. Please notify our office immediately so we can get you in touch with Dr. Fara for any concerns or issues.
● In the event of an emergency, call 911 immediately.

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THIS TREATMENT, OR ANY QUESTIONS CONCERNING THIS PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK NOW BEFORE SIGNING THIS CONSENT FORM.

By signing, I certify that I have read and understand the contents of this form. I am aware of the possible side effects and drug interactions and give my consent for treatment. I have informed the medical staff of any known allergies to drugs or other substances, and any past adverse reactions I’ve experienced. I have informed the medical staff of all medications and supplements I’m currently taking. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and acknowledge that no guarantees have been made to me concerning my results.

RELEASE FROM MEDICAL LIABILITY AND MALPRACTICE CLAIMS:

I agree to release Dr. Fara Movagharnia and Nyah Med Spa and all their associates from all medical liability and malpractice claims related to any and all care.

This consent covers the initial and all future prescriptions for this medication.

I understand that this is a prescription therapy and is not eligible for a refund or reimbursement.

I have read and agree to the above. My questions have been answered and I understand the treatment and goals. I understand and accept the potential risks associated with Semaglutide / Tirzapatide as stated above and consent to treatment.

I agree to release Dr. Fara Movagharnia and Nyah Med Spa and all their associates from all medical liability and malpractice claims related to any and all care.

Please check below:

I agree

I have read through all the above information and if I have questions I will ask the doctor.

Please check below:

 I agree

I certify that I have been informed of the risks and benefits of off-label treatment.

Please check below:

 I agree

I will review the side effects of all medications I am prescribed and immediately inform the doctor of any side effects.

Please check below:

 I agree

Medical Disclaimer

Patient agrees to virtual e-visit service terms, privacy policy, for receiving a virtual visit from Dr. Fara Movagharnia at Nyah Med Spa. Requests for e-visits must be confirmed and scheduled by our office prior to the e-visit. Prior to the visit please fill out all medical forms for Semaglutide. After reviewing your information, or during the e-visit it may be determined that your problem is too complex for an e-visit session. In that case our office will schedule you for a traditional office visit with Dr. Fara. Our physician appropriately documents the virtual e-visit, including all pertinent communication related to the encounter, in the patient’s medical/health record. The physician has a defined period of time within which responses to a virtual e-visit request are completed. During the virtual e-visit, the physician may make recommendations, provide medical advice and/or prescribe, refill or recommend medications. The physician may suggest the patient receive additional care, examination, testing and/or treatment at a medical facility in-person. If necessary, the physician may also suggest that the patient receive care in an emergency room. Communication during an e-visit may be exchanged via teleconference, landline phone, cellular phone and online chat per state of Georgia. By requesting an e-visit you acknowledge that personal health information will be communicated. A virtual e-visit may include the total interchange of online inquiries and other communications associated with this single patient encounter, subject to determination of the physician. As with any medical service, decision, or treatment, there are risks; and, an e-visit is no different. Because this visit is electronic and not in person, you acknowledge that the risk may be greater than a traditional office visit, and by requesting the visit you agree to accept the outcome-even if it is undesirable. In addition, you agree to abide by our office's routine policies including any policy related to litigation. I acknowledge I am receiving a telemedicine consult with the physician and the outcome will be based solely on the physician's medical discretion.

Signature

I acknowledge and agree that I have read the Medical Disclaimer above and I am authorizing Dr. Fara Movagharnia and any staff member of Nyah Med Spa , if present to proceed with our telemedicine visit.

Date

I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.

Please sign:

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:

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: