Ultrasound Cavitation Treatment And Radio Frequency

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Ultrasound Cavitation Treatments(Check all that apply):*

All costs are payable in-full at initial treatment and are non-refundable. Payments must be completed for entire package price (1, 4, 6, or 8 sessions) on first visit to receive package discount. Packages once purchased and treatment initiated are non-refundable and non-transferable.

All treatments must be used in a 30 day period beginning from the first session.

Medical Background (Check all that apply):

IF YOU ANSWERED “YES” TO ANY OF THESE QUESTIONS YOU MAY NOT BE ELIGIBLE FOR THE TREATMENT. Please explain any that you checked:

Are you presently taking any medications? List:*

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CONSENT TO TREATMENT: I understand this treatment is a process and subsequent visits are necessary in order to achieve the desired results. Subsequent visits are subject to additional charges per visit which depend on the amount of work needed. Actual results vary from person to person and Ashley Lynn Esthetics does not guarantee any specific result. The Ultrasound Cavitation treatment carries with it possible health complications and consequences, which include but might not be limited to the risk of kidney failure, liver failure, pacemaker failure, birth defect, miscarriage, thyroid damage, damage to the ovaries, lactation complications, hyper-triglyceridemic, hypercholesterolemia, pancreatitis, infection, scarring and/or allergic reaction to any products used, excessive thirst, dehydration, nausea. The Ultrasound Cavitation treatment includes, but is not limited to, the use of high-power low-frequency ultrasound cavitation which uses 30KHz frequency ultrasound to penetrate the skin and assist with the breakdown of fat cells by creating micro-bubbles that increase the pressure around the adipocyte and force it to implode, thus breaking down adipocyte’s cell membrane.*

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DOCUMENTATION/PICTURES: I understand Before, During and After Pictures will be taken. Before, during and after pictures or videos may be taken to document the treatment. These pictures or videos become Ashley Lynn Esthetics sole property and may only be used for its legitimate business purposes.*

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Release: I recognize that there are certain inherent risks associated with the above-described treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release and forever discharge Ashley LYnn Esthetics (including its officers, members, owners, employees and agents) from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether or not on account of myself, Ashley Lynn Esthetics or other third parties, or in any way arising out of the above described treatment I have requested Ashley Lynn Esthetics to perform. It is the intention of the parties that this agreement binds all parties whose claims may arise out of or relate to the treatment or services provided by Ashley LYnn Esthetics including any spouse or heirs of the client/patient and any children, whether born or unborn. Any legal or equitable claim that may arise from participation in the treatment shall be resolved under New York State Law. I agree to indemnify, hold harmless and defend Ashley Lynn Esthetics (including its officers, members, owners, employees and agents) against all third-party claims, causes of action, damages, judgments, costs or expenses, including attorneys’ fees and other litigation costs, which may in any way arise from the above described treatment I have requested Ashley Lynn Estheics to perform.

By signing this agreement I confirm that I am over the age of 18, I understand that the Ultrasound Cavitation procedure is permanent, that such procedure has possible adverse consequences and that the procedure is for cosmetic purposes only. I certify that I have read the above paragraphs; fully understand this consent and procedure form and herby consent to the indicated procedure(s). This means that I accept full responsibility for these and/or any other complications which may arise or result during or following the Ultrasound Cavitation procedure which is to be performed at my request according to this agreement and I herby agree to arbitration of any malpractice claim. I further understand that by signing this agreement, I surrender certain legal rights.

I understand that Ashley Lynn Esthetics only accepts cash as a form of payment for services and products. I understand that my Credit Card was kept on file for Cancellation and no show purposes when booking my appointment that is why I filled in that information and did not actually pay for my service. I understand that if I am a no show or if I do not give the proper 48 hour notice of canceling for any reason that my card will be charged the cancellation fee and/or I will lose the visit from any package I may have.( complete policies are listed on the website at ashleylynnesthetics.com)

I understand that there is NO ATM located at Ashley Lynn Esthetics. I understand that if I ever need a total before my service because I will need products as well I can reach out to Ashley and she can give me a total on anything that I need ahead of time so I am prepared.

I understand that all sales are final on products and no refunds will be issued on services rendered as it is impossible to give back time and products

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