• Treatment Agreement and Consent Form

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  • Medical History

  • By signing below, I agree to the following:
    I have completed this form to the best of my ability and knowledge. I agree to inform the
    technician of any changes in the above information. I agree that I do not have any condition(s)
    that would make the requested treatment unsuitable. I will inform the technician of any
    discomfort I may experience at any time during my treatment to allow them to adjust
    accordingly. I agree to waive all liability toward my technician and the salon for any injury or
    damages incurred due to any misrepresentation of my health.

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  • Photograph and Video Release Form

  • I         hereby grant and authorize      the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all
    pictures, video, and/or audio taken of me to be used in and/or for any lawful promotional
    materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites and other print or digital communications without payment or any other consideration.
    This authorization extends to all languages, media, formats, and markets now known or later discovered.
    I waive the right to inspect or approve the finished product wherein my likeness appears,
    including written or electronic copy.
    Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.
    I hereby hold harmless and release      from all liability, petitions,
    and causes of action which I, my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate.

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  • Yesotherapy

  • I         duly authorize the technicians of Essence Beauty LLC to perform Yesotherapy for the purpose of spot fat reduction/ improvement of cellulite,and/
    or butt & breast enhancement. I am aware that clinical results may vary depending on individual factors including but not limited to medical history, client compliance with pre-
    care and post-care treatment instructions,and individual bodily response to treatment.
    I have been made aware that my diet and the amount of exercise I do will have a major
    effect on the results of my treatments. If I do not make an effort to address my dietary
    requirements and exercise I am aware that the results achieved may not be retained.
    I understand that this body contouring service involves a course of treatment and all sales are final. Services and treatment packages are non-refundable and non- transferable. The fee structure has been fully explained and I understand that I am required to pay for a course of treatments prior to any procedures taking place.
    I am fully aware that should I wish to cancel the course the outstanding treatment value
    is non-refundable.

  • Individuals with any of the following conditions or net candidates for treatment with any
    of our body contouring lasers.

    Contraindications include:
    Pregnancy (within 6 months)
    Epilepsy
    Uncontrolled Thyroid Gland Dysfunction
    Uncontrolled Hypertension
    Cardiac Arrhythmias or Heart Disease
    Pacemakers
    Recent or current history of cancer or actively undergoing radiation or chemotherapy
    Liver/kidney disease
    Photosensitivity to 650 to 660nm of light
    Immuno-suppressed disorders
    Current infection (including viral)
    Currently not on Menstrual Cycle or haven’t been in the last 2 days

    Individuals must reframe from the use of blood thinners, antibiotics (with-in 10days prior
    to treatment), steroids (3 weeks prior).

  • I understand that with some skin types, there is a risk of temporary redness and/or
    discoloration of the skin localized in the treatment area that can last up to several hours.
    There is also a possibility of tattoo lightening if located in the treatment area.

    I certify that I have been fully informed of the nature and purpose of the procedure,
    expected outcomes, and possible complications. I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of a cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.

    I understand that it is my personal responsibility to inform the laser technician of the clinic named above of any changes to my medical history during the course of laser body contouring treatment sessions. I confirm that should this occur, I shall advise the technician of any changes.

    I certify that I have been given the opportunity to ask questions, any questions have been answered to my satisfaction, and that I have fully read and understood the contents of this consent form.

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