If I experience pain or discomfort during the session, I will immediately inform my technician so that the treatment can be adjusted to my level of comfort. I will not hold my technician responsible for any pain or discomfort I experience during or after the session.
I understand that the services offered today are not a substitute for medical care. I understand that my technician is not qualified to diagnose, prescribe, or treat physical or mental illness.
I affirm that I have notified my technician of all known medical conditions and injuries.
I affirm that I have properly hydrated as advised by my technician prior to my appointment.
I agree to inform the technician of any changes in my health and medical condition. I understand that there shall be no liability on the technician’s part should I forget to do so.
I understand there are no guarantees as to the results of this treatment.
I understand there are no refunds for this treatment.
I understand that to achieve maximum results, I may require several treatments.
To achieve maximum results, I understand diet and regular exercise will assist to sustain and create accumulative degree of overall spot fat reduction and body contouring.
I have been informed and I understand the temporary hyperpigmentation / hypopigmentation on rare occasion may occur as a result of treatment. I hereby certify that all information that I have provided has been accurate and truthful.
I hereby authorize Camellia Alise, LLC to perform Lipo Laser and cavitation procedures for the purpose of aesthetic body contouring and girth.
Client agrees to keep and obey all rules and regulations now in force or in the future prescribed by Camellia Alise, LLC. Camellia Alise, LLC, reserves the right to revoke this agreement for cause if patron fails to keep and obey any such rules and regulations.
This Release and Waiver is entered into by and between Camellia Alise, LLC (“Provider”) and the undersigned client (“Client”), effective on the date written below. In consideration of Provider permitting Client to receive wellness treatments (“Treatment”) at Provider, Client agrees as follows:
Disclosure. This treatment is a process and subsequent visits may be 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 Provider does not guarantee any specific result. The Ultrasound Cavitation/Radio Frequency 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-triglyceridemia, hyper-cholesterolemia, pancreatitis, infection, scarring and/or allergic reaction to any products used, excessive thirst, dehydration, nausea. The Ultrasound Cavitation/Radio Frequency treatment includes, but is not limited to, the use of high-power low-frequency ultrasound cavitation which uses 25-40KHz 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 the adipocyte’s cell membrane. Radio Frequency treatments tighten skin.
After Care. After care instructions must be followed explicitly, whether given in writing or orally. Failure to follow after care instructions may compromise the final results of the treatment.
Before, During and After Pictures. Before, during and after pictures or videos may be taken to document the treatment. These pictures or videos become Provider sole property and may only be used for its legitimate business purposes.
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 Provider(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, Provider or other third parties, or in any way arising out of the above described treatment I have requested Provider 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 Provider 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 Texas law.
I agree to indemnify, hold harmless and defend Provider(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 Provider perform.
Arbitration. It is understood that any dispute arising as to malpractice of the Ultrasound Cavitation treatment shall be decided by a neutral arbitrator. Any arbitration proceeding will be governed by Texas arbitration statute, the fees for the arbitrator will be split pro-rata among the parties and each party will be responsible for their own attorneys’ fees and costs. Any action to collect fees from the client/patient for the treatments performed may be brought in any court located in Texas and the prevailing party in such collection action shall be entitled to recover its reasonable attorneys’ fees and costs. Filing of any action in any court to collect any fee from the client/patient shall not waive the right to compel arbitration of any malpractice claim.
By signing this agreement I confirm that I am over the age of 18, I understand that the Ultrasound Cavitation/Radio Frequency procedure stimulates permanent changes, 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 hereby agree to arbitration of any malpractice claim. I further understand that by signing this agreement, I surrender certain legal rights.
1. Drink (3) 16 oz bottles of water before your appointment and continue to drink water after your appointment and at least 2 liters of water the day after your treatment to flush out the melted fat.
2. Apply “Firm Up” cream before bed.
3. Avoid use of soap and lotions directly after your services.
4. We highly recommend the use of Spanx or a compression garment after your treatment to help with tightening and toning of the skin as well as assisting with lymphatic drainage.
5. To maximize the effectiveness of your sessions, restrict products that impact lymphatic flow during and after treatment [i.e. caffeine, alcohol and sugar in large amounts]
6. Do not shower immediately after treatment. This will remove the elements that are working wait at least 2 hours after treatment to shower.
7. Do not smoke during the process, smoking is bad for the circulation and will affect the treatment negatively.
8. We recommend eating a healthy diet to stabilize the fat and inches loss you obtain during the treatment.
9. After the session is over, do not immediately jump into the shower.
10. Always consult with your Physician before beginning any new Health & Diet Program.
11. Always inform us if you have a change in health status or experience any unusual symptoms during your program.
12. Tell us if your digestive process is affected in any way during a session. [constipation/diarrhea]
13. If you should become pregnant during this process please inform us immediately.
I hereby authorize Camellia Alise, LLC and its agents and employees to photograph and film for the purpose of education, publication, promotion, illustration, advertising, or trade, in any manner or in any medium and release Camellia Alise, LLC and its legal representatives for all claims and liability relating to said images or video.
Furthermore, I grant permission to use my statements that given during an interview or testimonial, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.
By signing below I acknowledge I have read and understand this release.