I hereby consent to the facial treatment...
I consent to have my pictures and/or videos taken and stored in the electronic medical record system of [Rhonda L D’Agostino Inc]. Such photographs and videos will not be used without my express permission for any purpose except internal training. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment prior to receiving services.
I further agree in the event of non-payment, cancellation of payment, or any payment issues, to bear the cost of collection, court costs, and legal fees, should those be required.
I consent to email, text and phone communications related to post-procedure care and follow-up appointments. I consent to receive promotional messages and marketing messages via email, phone and SMS messages from [Rhonda L D’Agostino Inc].
I do not have or have not had any major illnesses which would prohibit me from receiving this treatment. I have not had any dental procedures or vaccinations in the last 14 days.
I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to, lidocaine. I am completely of sound mind and am fully aware of all the risks and possible complications of this procedure. I understand this procedure is one hundred percent voluntary. I have read the material given to me and I am fully satisfied that all of my questions and concerns have been addressed.
I understand that I am required to attend post-procedure check-ups as advised by [Rhonda L D’Agostino Inc] and that I am required to follow all post-treatment instructions. I have received and fully understand the pre- and post-treatment instructions. I have advised my provider of my medical history including all previous medical conditions and medications currently being taken by me.
Alternatives to the procedures and options that I am choosing to get today have been fully explained to me. I am aware that there may be other risks or complications not discussed that may occur. I also understand that during the course of the proposed procedure, unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed.
I do not have:
Current or history of cancer, especially skin cancer, or pre-malignant moles;
Any active condition in the treatment area such as sores, hemorrhages or risk of hemorrhages, septic conditions, and rash as well as irritated or damaged skin due to excessive fresh tanning;
Vascular disorders such as: uncontrolled diabetes, nervous diseases, cardiac disorder and cancer. In such cases, consult the treating physician; or
Any aesthetic procedure done recently within the applied area or recent use of products such as Accutane® or Retin A®.
I was told about the possible side effects of the treatment including: local pain, excessive skin redness (erythema), excessive swelling (edema), damage to the natural skin texture (crust, blister, and burn), excessive tingling sensation, fragile skin and bruising. Although these effects are rare and expected to be temporary, any adverse reaction should be reported immediately.
I acknowledge that no guarantees or promises have been made to me concerning the results of this procedure or any treatment that may be required as a result of this procedure. I understand there are no refunds and that multiple treatments are often required to achieve noticeable and lasting outcomes. I also understand that promotional items have no refund value.
By accepting and signing, I acknowledge that I have read this informed consent, I understand it, and I agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent treatments with the above understood. I hereby release the Medical Director(s), the [Rhonda L D’Agostino Inc] provider performing the treatment, and [Rhonda L D’Agostino Inc] from liability associated with this procedure. I have been given the opportunity to ask questions and my questions have been answered to my satisfaction.
Post-treatment, I agree to comply with the following instructions:
Avoid sun exposure, saunas, and working out for 24 hours.
I understand some clients may experience a hypersensitive reaction to Hibiclens®, alcohol, or acetone, or to other prep or cleaning solutions.
ARBITRATION AGREEMENT – READ CAREFULLY
It is understood and agreed by [Rhonda L D’Agostino Inc] and I, as a recipient of services, that any legal dispute, controversy, demand or claim that arises out of or relates to the services provided to me by [Rhonda L D’Agostino Inc] or any other service provided by [Rhonda L D’Agostino Inc] to me shall be resolved exclusively by binding arbitration as provided by [New York State] law.
It is understood that any dispute as to medical malpractice (whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompletely rendered) will be determined by submission to arbitration and not in a court of law or before a jury.
It is in the intent of the parties that this agreement cover all existing or subsequent claims or controversies, whether in tort, contract, or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to the treatment of services provided or not provided by any employee, physician, nurse practitioner, registered nurse, association, partner, or agent affiliated with [Rhonda L D’Agostino Inc] to a patient. This party includes causes of action that might be brought on behalf of me by a spouse, heir, child (born or unborn), guardian or parent.
I read, write and fully understand English. I am of sound mind and body and have the full capacity to consent to this treatment.
By accepting and signing this consent, I acknowledge that I have read this informed consent, I understand it, and I agree to this treatment with its associated risks. I hereby give consent to perform this and all subsequent treatments with the above understood. I hereby release the Medical Director(s), [Rhonda L D’Agostino Inc] and the provider performing the treatment from liability associated with this procedure. I have been given the opportunity to ask questions and my questions have been answered to my satisfaction. I hereby consent to the facial and hereby authorize the [Rhonda L D’Agostino Inc] provider to perform the treatment.