New Client Packet

Welcome to Golden Laser Aesthetics, we look forward to getting to know you!
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example@example.com
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How did you hear about us?
Please tell us your main concerns that brought you to our office today:

Release from Responsibility, Assumption of Risk, and Waiver
PLEASE READ THIS DOCUMENT CAREFULLY AND COMPLETELY BEFORE SIGNING. ITS EFFECT IS TO RELEASE GOLDEN LASER AESTHETICS, LLC (GLA), A COLORADO LIMITED LIABILITY COMPANY, AND ITS AFFILIATED PERSONS AND ENTITIES FROM ANY LIABILITY RESULTING FROM TREATMENTS PROVIDED TO YOU, AND TO WAIVE ALL CLAIMS FOR DAMAGES OR LOSSES AGAINST GLA WHICH MAY ARISE FROM SUCH TREATMENTS EVEN IF THEY RESULT FROM NEGLIGENCE.

By signing in the space provided below, I expressly agree to the following:
1. I hereby acknowledge and agree that GLA offers a variety of treatments for use by members and customers solely at their own risk. I understand and acknowledge that GLA makes no claims as to the safety, results, or the appropriateness of any program, activity, and/or treatment for any particular person. Furthermore, I understand that GLA reserves the right to exclude any person from participating in any program, activity, or treatment for any reason whatsoever.*

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2. I further acknowledge and agree that participation in GLA programs and treatments may involve a high degree of risk and at times may be hazardous to my health. I expressly agree to assume all risk associated therewith and agree to forever waive any and all claims and legal rights which I may have whatsoever, to the extent permitted by law, in connection with my participation in any GLA treatment or program.*

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3. I understand that before participating in any GLA program or treatment I should consult my physician and in the event my health condition changes during a program or treatment, I agree to consult with my physician prior to resuming any and all programs/treatments with GLA. I understand and agree that all suggestions and/or instructions made by GLA staff are neither diagnostic nor prescriptive and that I should verify the same with my physician and I will evaluate such instructions and/or suggestions independently. Notwithstanding the foregoing, I warrant and represent that I am in good health and that I am able to participate in GLA treatments/programs, without limitation.*

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4. I agree to notify GLA if I experience any adverse reactions to any GLA program or treatment or to call 911 if the post-procedure issue is an emergency. I agree to visit the offices of GLA for examination, documentation, and treatment of any post-procedure adverse reactions and agree to take reasonable steps to keep GLA informed of my condition until the post-procedure adverse reaction has been resolved to the extent possible.*

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5. IN CONSIDERATION OF TAKING PART IN GLA TREATMENTS/PROGRAMS, I AGREE, TO THE FULLEST EXTENT PERMITTED BY LAW, TO FOREVER RELEASE, INDEMNIFY, DEFEND AND HOLD HARMLESS GLA; ITS SUBSIDIARIES AND AFFILIATES; AND THEIR RESPECTIVE AGENTS, MEDICAL DIRECTORS; OFFICERS, DIRECTORS, OWNERS, CONTRACTORS, AND EMPLOYEES (COLLECTIVELY THE “RELEASED PARTIES”) FROM ANY AND ALL CLAIMS AND CAUSES OF ACTION WHICH I MIGHT OTHERWISE HAVE OR BE ENTITLED TO ASSERT AS A RESULT OF OR RELATED TO ANY PHYSICAL INJURY OR OTHERWISE, INCLUDING WITHOUT LIMITATION DEATH OR PROPERTY DAMAGE OR LOSS SUSTAINED IN CONNECTION WITH PARTICIPATION IN ANY GLA PROGRAM OR TREATMENT, INCLUDING, WITHOUT LIMITATION, CLAIMS AND CAUSES OF ACTION BASED ON NEGLIGENCE, BREACH OF WARRANTY, OR BREACH OF CONTRACT. I ALSO AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE RELEASED PARTIES FROM ANY AND ALL CLAIMS BROUGHT BY THIRD PARTIES ARISING OUT OF MY ACTS, ERRORS OR OMISSIONS.*

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6. I hereby authorize GLA personnel to call for medical assistance for me and to transport me to a medical facility or hospital in the event of an emergency. I further agree to be responsible for all costs and expenses associated with any such medical care and/or related transport and I hereby indemnify and hold harmless the Released Parties of and from any such costs.*

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7. I agree to follow the pre and post-treatment instructions provided by GLA and agree to wear eye protection if requested to.*

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8. I agree to abide by all rules and regulations as may be established from time to time by GLA.*

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9. I understand that this procedure is elective and that payment is my responsibility and is expected in full at the time of the treatment. I understand that if my form of payment is rejected that I must provide another form of payment immediately or will be charged an interest rate of 10% per day until the full amount is paid. I understand that forms of payment such as PayPal may incur additional charges.*

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10. I agree to allow my treatment photos, testimonials, and/or videos to be used for promotional purposes, including but not limited to GLA’s website and social media accounts. I waive any right to inspect or approve the finished product. I understand that my name and identifying information will NOT be used. I hereby grant and convey unto GLA all right, title, and interest in any and all photographic images and video or audio recordings made by GLA and its members, officers, agents, and any other persons or entities acting on their behalf.

I agreeeI DO NOT agree to allow the use of my treatment photos, testimonials, and/or videos for promotional purposes.
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11. This Agreement shall be binding on my estate, heirs, administrators, and assigns. *

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I understand that this is an elective procedure. The procedure has been fully explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and that there are no guarantees of the outcome. I certify that if there have been any changes in my medical history or medication use that I will notify the personnel at Golden Laser Aesthetics, LLC immediately. I will direct all post-procedure questions to the personnel at Golden Laser Aesthetics, LLC. I understand that the personnel at Golden Laser Aesthetics, LLC do not make house calls and address post-procedure concerns at its facilities. I agree to call 911 if the post-procedure issue is an emergency. I also confirm that I read and write in English.
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First NameLast Name
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Welcome to Golden Laser Aesthetics, we look forward to getting to know you!

Office Use

Skin Typing Worksheet

Financial Agreement and Consultation Form

Client Skin Concerns

Release from Responsibility, Assumption of Risk, and Waiver