Consent - Body by Yashi

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Consent form for additional services

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Post Op Care Manual Lymphatic drainage is a form of gentle massage that encourages the movement of lymph fluids around the body. The fluid in the lymphatic system helps remove waste and toxins from the bodily tissues. Patient Agreement: I acknowledge that I am a competent, consenting adult of at least 18 years of age, and further, that in signing this agreement understand that I am beginning a series of post op care treatments such as MLD Manual Lymphatic Drainage (lymphatic massages), seroma treatment, drain removal, suture removal or Platelet Rich Plasma (PRP) treatments, to help heal after surgery. I do understand that not all treatments will have the same results on every client, therefore no guarantee can be given. The treatments I receive here are voluntary and I release BODY BY YASHI GORDON RPN, PLLC from liability and assume full responsibility thereof. I acknowledge any and all treatments does not claim to cure or treat any condition or disease. I acknowledge that BODY BY YASHI GORDON RPN, PLLC has the right to refuse service and the use of the facilities to any person whose conduct is harassing, offensive, inappropriate or is an unreasonable disturbance to other clients, guests, vendors, employees, agents, and/or independent contractors, and that any such conduct which shall result in the Client’s expulsion and termination of the use of its related services, without refund of moneys advanced for such use and services. Risk: I have been informed and I understand that inflammation, erythema (redness), temporary hyperpigmentation/hypopigmentation may occur as a result of treatment. Contraindications: There are contraindications for post op treatments that include, but not limited to, pregnancy, nursing, infectious skin disease, recent infections, uncontrolled high blood pressure, heart problems, untreated thyroid disease and other hormonal disorders, pacemaker, any type of metal implants, blood clots, people on blood thinners, deep vein thrombosis, allergies, epilepsy, liver or kidney malfunction, lupus, untreated diabetes, auto immune diseases, 250lbs limit, and cancer of any type. If you have a medical condition, it is imperative that you receive physician approval prior to treatment. I have read and understand the information provided in this form • I have had my treatment adequately explained to me by my clinician • I have had the opportunity to ask questions, and all my questions have been answered • I have received all the information I desire concerning my treatment • I understand all post treatment recommendations and agree to adhere to them • I freely assume any risks of complications or injury from known or unknown causes associated with, relating to, or otherwise arising out of this procedure • I have the right to consent to or refuse any proposed procedure at any time prior to its performance. • I must notify the clinician if my medical history changes prior to subsequent treatments • I consent to photographs of the treatment area CLIENT RELEASES, WAIVES, DISCHARGES BODY BY YASHI GORDON RPN, PLLC OR ANY OF ITS OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, INDEPENDENT CONTRACTORS, SHAREHOLDERS, INSURANCE COMPANIES, ATTORNEYS, AFFILIATES, SUBCONTRACTORS, VENDORS, LANDLORDS, LESSORS, AND/OR ITS SUCESSORS IN INTEREST (COLLECTIVELY, “RELEASEES”) HARMLESS FROM ALL CLAIMS, ACTIONS, OR DEMANDS CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY RELATED SERVICES. I HAVE CAREFULLY READ THE ABOVE USE AGREEMENT, WAIVER AND RELEASE OF LIABILITY AND UNDERSTAND THAT I HAVE GIVEN UPRIGHTS BY SIGNING IT AND SIGN IT VOLUNTARILY. *

I agree

IV/IM Vitamin I hereby authorize the following procedure: Administration of intravenous and intramuscular (IM) vitamins, minerals, and other nutrients. This procedure is recommended for replacement of these essential nutrients, correction of deficiencies, and for other therapeutic effects, such as improving immune function, improving antioxidant status, reducing oxidative damage, improving fatigue, etc. The principal side effects that may accompany intravenous administration of nutrients include: • burning and stinging at the site of injection/infusion or if IV infiltrates into surrounding tissue • muscular spasms, weakness, or fatigue • allergic reactions (rare) • local thrombophlebitis (very rare). Based on the risks and potential benefits of the current medically indicated treatment(s) and of this proposed treatment, I have elected to forego or supplement the indicated treatment(s) and receive this proposed treatment from the health care professionals at BODY BY YASHI GORDON RPN, PLLC as is appropriate and necessary for my care. I acknowledge that I am a competent, consenting adult of at least 18 years of age, and further, that in signing this agreement understand that This procedure may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been prescribed. This therapy has been recommended to you in the belief that it is of potential benefit in these circumstances and its use will quite probably improve the condition for which you are under treatment and in your overall health. I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the procedure, except as that claim pertains to negligent administration of this procedure. The risks involved and the possibilities of complications have been explained to me. I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer-reviewed publications and therefore may be considered medically unnecessary or not currently indicated. I hereby place myself under your care for intravenous or intramuscular vitamin therapy, and agree to the above release. I also verify that all information presented to medical provider in my medical history is true to the best of my knowledge. I am not misrepresenting myself and I place myself under your care for the sole purpose of treatment. CLIENT RELEASES, WAIVES, DISCHARGES BODY BY YASHI GORDON RPN, PLLC OR ANY OF ITS OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, INDEPENDENT CONTRACTORS, SHAREHOLDERS, INSURANCE COMPANIES, ATTORNEYS, AFFILIATES, SUBCONTRACTORS, VENDORS, LANDLORDS, LESSORS, AND/OR ITS SUCESSORS IN INTEREST (COLLECTIVELY, “RELEASEES”) HARMLESS FROM ALL CLAIMS, ACTIONS, OR DEMANDS CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY RELATED SERVICES. I HAVE CAREFULLY READ THE ABOVE USE AGREEMENT, WAIVER AND RELEASE OF LIABILITY AND UNDERSTAND THAT I HAVE GIVEN UPRIGHTS BY SIGNING IT AND SIGN IT VOLUNTARILY. *

I agree

Body Contouring Body sculpting increases flow of both the lymphatic and circulatory systems. The main use of body sculpting treatment is inch loss, diminishing cellulite and tightening of the skin. This is not a weight loss treatment. The inches will return if the patient goes back to their old habits. A series of 5-10 body sculpting treatments are recommended per area, but some individuals may require more treatments to achieve maximum results. There should be at least 5-7 days between each treatment. Limitation to Treatment: I understand there are no guarantees as to the results of this treatment. I understand that to achieve maximum results, I may require several treatments. To achieve optimum results, I understand that a balanced diet and regular exercise will improve overall fat reduction and body contouring. Risk: I have been informed and I understand the temporary hyperpigmentation/hypopigmentation on rare occasion may occur as a result of treatment. Ensure Your Best Results: • Drink plenty of fluids before and after each treatment(s) • Avoid meals 2 to 4 hours prior to treatment(s) • Perform physical activity following each treatment to maximize your results • Manage caloric intake; excess calories will counteract your progress • Alcoholic beverages and high sugar content drinks must be avoided before and after treatment(s) Contraindications: There are contraindications for body contouring treatments that include, but not limited to, pregnancy, nursing, infectious skin disease, recent infections, uncontrolled high blood pressure, heart problems, untreated thyroid disease and other hormonal disorders, pacemaker, any type of metal implants, blood clots, people on blood thinners, deep vein thrombosis, allergies, epilepsy, liver or kidney malfunction, lupus, untreated diabetes, auto immune diseases, 250lbs limit, and cancer of any type. If you have a medical condition, it is imperative that you receive physician approval prior to treatment. Patient Agreement: I acknowledge that I am a competent, consenting adult of at least 18 years of age, and further, that in signing this agreement understand that I am beginning a series of treatments to help reach my goals of body contouring, skin tightening and spot fat reduction. I do understand that not all treatments will have the same results on every client, therefore no guarantee can be given. The treatments I receive here are voluntary and I release BODY BY YASHI GORDON RPN, PLLC from liability and assume full responsibility thereof. I acknowledge any and all treatments does not claim to cure or treat any condition or disease. I acknowledge that BODY BY YASHI GORDON RPN, PLLC has the right to refuse service and the use of the facilities to any person whose conduct is harassing, offensive, inappropriate or is an unreasonable disturbance to other clients, guests, vendors, employees, agents, and/or independent contractors, and that any such conduct which shall result in the Client’s expulsion and termination of the use of its related services, without refund of moneys advanced for such use and services. • I have read and understand the information provided in this form • I have had my procedure adequately explained to me by my clinician • I have had the opportunity to ask questions, and all my questions have been answered • I have received all the information I desire concerning my procedure • I understand all post treatment recommendations and agree to adhere to them • I freely assume any risks of complications or injury from known or unknown causes associated with, relating to, or otherwise arising out of this procedure • I have the right to consent to or refuse any proposed procedure at any time prior to its performance. • I must notify the clinician if my medical history changes prior to subsequent treatments • I consent to photographs of the treatment area CLIENT RELEASES, WAIVES, DISCHARGES BODY BY YASHI GORDON RPN, PLLC OR ANY OF ITS OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, INDEPENDENT CONTRACTORS, SHAREHOLDERS, INSURANCE COMPANIES, ATTORNEYS, AFFILIATES, SUBCONTRACTORS, VENDORS, LANDLORDS, LESSORS, AND/OR ITS SUCESSORS IN INTEREST (COLLECTIVELY, “RELEASEES”) HARMLESS FROM ALL CLAIMS, ACTIONS, OR DEMANDS CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY RELATED SERVICES. I HAVE CAREFULLY READ THE ABOVE USE AGREEMENT, WAIVER AND RELEASE OF LIABILITY AND UNDERSTAND THAT I HAVE GIVEN UPRIGHTS BY SIGNING IT AND SIGN IT VOLUNTARILY. *

I agree

Teeth Whitening I acknowledge that am purchasing self-administered Teeth Whitening Kit that is designed to whiten the color of my teeth. As a part of the purchase, I am asking for assistance in the use of my teeth whitening kit, and I understand that I will be allowed to use a specially designed LED Lamp in order to accelerate the whitening process. Although most natural teeth can benefit from a teeth whitening treatment, I understand that everyone's teeth are different and that results will vary. I understand that people with yellowish teeth generally get the best results and that if my teeth have spots due to tetracycline use (grayish tint) or fluorosis, these will be difficult to whiten. Also, if have artificial teeth, caps, crowns, veneers, porcelain, composite or other restorative materials, I shouldn't expect dramatic results from this treatment because the peroxide gel will not whiten (or damage) artificial dental work. Also, I am aware that my teeth will never be whiter than the white color my genes naturally Potential Risks Although whitening treatments are generally safe, I understand that some of the potential complications of this treatment include, but are not limited to: GUM/LIP IRRITATION: Whitening gel that comes in contact with gum tissue or the lips during the treatment may cause inflammation or whitening of theses areas. This is due to inadvertent exposure of small areas of those tissues to the whitening gel. The inflammation and/or whitening of gums and lips is transient, and the color change of the gum tissue will reverse within 30 minutes. I may feel a stinging and tingling sensation on these soft tissues during the treatment if the gel comes in contact with them. ALLERGIC REACTION: A small percentage of people are allergic to peroxide. Should allergic reaction occur, temporary blisters and swelling on lips can occur. TOOTH SENSITIVITY: Although uncommon, some customers can experience some tooth sensitivity during the first 24 hours after the whitening treatment. People with existing sensitivity, recently cracked teeth, micro-cracks, open cavities, leaking fillings, exposed roots, or other dental conditions that cause sensitivity may find that those conditions increase or prolong tooth sensitivity after the treatment. SPOTS OR STREAKS: Some customers may develop white spots or streaks on their teeth due to CALCIUM DEPOSITS that naturally occur in teeth. These spots are NOT caused by the peroxide gel. The gel just brings the already existing calcium deposits out and makes them visible again. These usually diminish over time. RELAPSE: After the treatment, it is natural for teeth color to regress somewhat over time. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents, such as coffee, tea, tobacco, wine, colas, etc. I realize that I should not eat or drink anything except water during 60 minutes after the treatment because the gel opens the pores of my enamel and makes my teeth very vulnerable to staining agents. If I purchase a touch-up pen, I realize that my pores will remain open for as long as I use it so I should refrain from staining agents till stop using the pen. Only 24 hours after I conclude the touch-up pen treatment can I resume my normal habits. I understand that the results of the treatment are not intended to be permanent and that secondary, repeat or touch- treatments may be needed for me to maintain the color I desire for my teeth. Eligibility I understand that this treatment CANNOT be used by pregnant or lactating women , people under the age of 1 people with gum disease, open cavities, leaking fillings, or other dental conditions, or people with a known allergy to peroxide and/or to aloe vera. People that have had braces removed should wait 6 months for cement residue wear off before getting a teeth whitening treatment and people with a piercing or other metal objects in the on cavity should remove them before the treatment as they may turn black. If I feel a sharp pain on a particular tooth during the treatment, I should stop the treatment and contact my dentist since this could be a sign of an open cavity By signing this document, indicate that I am not ineligible as per the criteria listed above, that have read and understand this entire document including the possible risks, complications and benefits that can result from the treatment that I am performing this treatment under my own responsibility. I also certify that I HAVE HEALTHY GUMS. *

I agree

Vagi Spa I hereby authorize the following procedure: Yoni Vaginal Steam Yoni (vaginal) steaming is a holistic health practice in which a woman allows the warmth of herbal steam to gently permeate her vagina. This holistic procedure is recommended to detoxify the womb, regulate monthly bleeding, treatment for stress, increase fertility, relief from menopause symptoms, decrease fatigue, relieve hemorrhoids & improve energy. The principal side effects that may accompany yoni steaming include • Abdominal cramps • Vaginal Discharge or bleeding • Local burn to surrounding tissue and skin • Imbalance in vaginal pH • Allergic reactions (rare) CONTRAINDICATIONS Women who are pregnant or think there is any possibility that they might be, should NOT do any type of yoni steam. Doing so may endanger the pregnancy, as many of the herbs used can alter hormone levels and can cause contractions of the uterus. For the same reason, it is also not recommended for women who have an Intrauterine Device (IUD). Women who have any type of internal infection (cervical, uterine or ovarian inflammation), or a fever, are encouraged not to steam until the symptoms have passed. Women also should not steam while menstruating or when open sores or blisters are present. Based on the risks and potential benefits of the current medically indicated treatment(s) and of this proposed treatment, I have elected to forego or supplement the indicated treatment(s) and receive this proposed treatment from the health care professionals at BODY BY YASHI GORDON RPN, PLLC as is appropriate and necessary for my care. I acknowledge that I am a competent, consenting adult of at least 18 years of age, and further, that in signing this agreement understand that This procedure may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been prescribed. This therapy has been recommended to you in the belief that it is of potential benefit in these circumstances and its use will quite probably improve the condition for which you are under treatment and in your overall health. I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the procedure, except as that claim pertains to negligent administration of this procedure. The risks involved and the possibilities of complications have been explained to me. I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer-reviewed publications and therefore may be considered medically unnecessary or not currently indicated. I hereby place myself under your care for intravenous or intramuscular vitamin therapy, and agree to the above release. I also verify that all information presented to medical provider in my medical history is true to the best of my knowledge. I am not misrepresenting myself and I place myself under your care for the sole purpose of treatment. CLIENT RELEASES, WAIVES, DISCHARGES BODY BY YASHI GORDON RPN, PLLC OR ANY OF ITS OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, INDEPENDENT CONTRACTORS, SHAREHOLDERS, INSURANCE COMPANIES, ATTORNEYS, AFFILIATES, SUBCONTRACTORS, VENDORS, LANDLORDS, LESSORS, AND/OR ITS SUCESSORS IN INTEREST (COLLECTIVELY, “RELEASEES”) HARMLESS FROM ALL CLAIMS, ACTIONS, OR DEMANDS CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY RELATED SERVICES. I HAVE CAREFULLY READ THE ABOVE USE AGREEMENT, WAIVER AND RELEASE OF LIABILITY AND UNDERSTAND THAT I HAVE GIVEN UPRIGHTS BY SIGNING IT AND SIGN IT VOLUNTARILY. *

I agree

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