Cryoskin Assumption of Risk, Waiver, and Release

By engaging Bella Lash & Beauty Bar (“Company”) to perform the Cryoskin treatments (“Services“), I hereby acknowledge on behalf of myself, my heirs, personal representatives and/or assigns, that there are certain inherent risks and dangers associated with receiving the Service. At all times, I shall comply with all stated and customary terms, posted safety signs, rules, and verbal instructions given to me by staff. If in the subjective opinion of the Company staff, I would be at physical risk in receiving the treatment, I understand and agree that I may be denied the treatment until I furnish the Company with an opinion letter from my medical doctor, at my sole cost and expense, specifically addressing the Company’s concerns and stating that the Company’s concerns are unfounded.

I hereby (1) agree to assume full responsibility for any and all injuries or damage which are sustained or aggravated by me in relation to my receiving of the Services, (2) release, indemnify, and hold harmless the Company, its direct and indirect parent, subsidiary affiliate entities, and each of their respective officers, directors, members, employees, representatives and agents, and each of their respective successors and assigns and all others, from any and all responsibility, claims, actions, suits, procedures, costs, expenses, damages, and liabilities to the fullest extent allowed by law arising out of or in any way related to the Services, and (3) represent that: (a) I have no medical or physical condition that would prevent me from receiving the Services, (b) I do not have a physical or mental condition that would put me in any physical or medical danger, (c) I have not been instructed by a physician to not receive Services, (d) no warranty or guarantee, or other assurance, has been made to me covering the results of the Services, (e) knowing the risks involved I nevertheless chose to voluntarily request the Services. Notwithstanding the foregoing (and by way of illustration only and not limitation) if any of the following apply to me or if I’m unsure for any reason, I hereby acknowledge the Company’s recommendation that I consult a medical physician before receiving Services.

Cryoskin should not be used on or applied to clients who have certain medical conditions and/or contraindications as listed below:

Contradictions for all Services (CryoSlimming, CryoToning Body, CryoToning Facial, and Electrical Muscle Stimulation (E-Stim))

Do you have a progressive disease (MS, ALS, Parkison’s, Neuropathy)?*

YesNo

Recent surgery to treatment area (within last 6 months)?*

YesNo

Do you suffer from Cold allergy or illnesses like: Raynaud's, Cryoglobulinemia, Paroxysmal Cold Hemoglobinuria, Cold Agglutinin Disease?*

YesNo

Do you have wound healing disorder?*

YesNo

Do you have active/severe Eczema, rashes, or dermatitis?*

YesNo

Do you currently have any open or infected wounds?*

YesNo

Do you have a pacemaker or metal implants in or adjacent to desired treatment area?*

YesNo

Do you have silicone or other implants in treated area?*

YesNo

Do you have irremovable body piercings in the desired treatment area?*

YesNo

Do you have Cardiovascular Disease or Lower Limb Ischemia?*

YesNo

Do you have bacterial and viral infections of the skin?*

YesNo

Do you have circulatory disorders?*

YesNo

Do you use of topical antibiotics in desired treatment area?*

YesNo

Do you have impaired skin sensation (desensitization)?*

YesNo

Do you have known sensitivity or allergy to propylene glycol?*

YesNo

Additional contradictions for CryoSlimming, CryoToning Body, Electrical Muscle Stimulation (E-Stim)

Are you pregnant, lactating or undergoing IVF?*

YesNo

Do you have any mesh inserts?*

YesNo

Additional contradictions for CryoSlimming

Do you have cancer or undergoing cancer treatment?*

YesNo

Do you have HIV/AIDS?*

YesNo

Do you suffer from severe kidney or liver disease?*

YesNo

Do you have any lymphatic drainage disorders?*

YesNo

Do you suffer from uncontrolled diabetes or diabetes related complications?*

YesNo

Do you have incision scar(s) in the desired treatment area?*

YesNo

Do you have hernia in or adjacent to desired treatment area?*

YesNo

Additional contradictions for CryoToning Facial

Have you had Botox in the past 30 days?*

YesNo

Have you had fillers or injections in the past 90 days?*

YesNo

Additional contradictions for Electrical Muscle Stimulation (E-Stim)

Do you have current or recent bleeding/hemorrhage?*

YesNo

Do you have a compromised circulation?*

YesNo

Do you have regenerating nerves?*

YesNo

Do you have impaired mental status?*

YesNo

Do you have over malignant tissue?*

YesNo

Please read the following statements, accept, and sign below to indicate that you have read the statement and understand it:

I understand that results may vary depending on individual factors including but not limited to medical history, prior treatments of area being treated, skin type, medication, hormones, patient compliance with pre/post session instructions and individual response to Services. I understand that I must maintain good dietary habits, have sufficient water intake and participate in light physical activity as well as comply with other items outlined during consultation.

I understand that the Services have not been tested or proven by the FDA or any other US government agency for the treatment of any illness or disease. I will be using this at my own risk.

My participation in the Services will expose me to extremely cold temperatures. I have read this Assumption of Risk, Waiver, and Release, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue the Company under certain circumstances. I acknowledge that I am signing this waiver freely and voluntarily. The term of this waiver is indefinite. Should any pain or discomfort occur, I will immediately notify the technician. I understand that I must be at least 15 years old to participate in the Services. I understand that all sales are final and refunds are not permitted.

I agree to have my photograph taken. I give permission for any photographs and other audio-visual and/or graphic materials to be used for marketing, education, and/or promotional purposes without any payment to me. I understand that although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I might be identified by the photos.

How did you hear about Bella Lash & Beauty Bar?

Friend/Other

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

DateTime

Signature*

Signature - Legacy*