Consultation - Body by Yashi

Your Information – Step 1 of 7

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General Consent I acknowledge that beauty treatments, the practice of skin care, and the practice of massage, including, but not limited to, electrolysis, skin tightening, body treatments, laser treatments, spot removal, micro needling, body peeling, waxing, and various other beauty procedures is not an exact science and no specific guaranties can or have been made concerning the outcome. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required in order to realize a difference. I also understand and agree to assume the following risks and hazards which may occur in connection with any particular treatment including but not limited to: unsatisfactory results, soreness, poor healing, discomfort, redness blistering, nerve damage, scaring, infection and change in skin pigmentation, allergic reaction, muscle damage, and increased hair growth. I understand that even through precautions may be taken in my treatment, not all risks can be known in advance. 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 response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend and hold harmless BODY BY YASHI GORDON RPN, PLLC and release from any and all liability the company and the individual that provided my treatment, the insured and any additional insureds, as well as any officers, directors, or employees of the above companies for any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive. I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect my treatment. I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration using a single arbitrator agreed to by both parties. Cancellation Policy Please be aware of our cancellation policy; we require 24 hours’ notice of all cancellations or a fee of $25 will be charged. 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

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

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