B. SWEET SERVICE WAIVER & CONCENT

First Name *

Last Name *

Phone Number ( NO SPACES ) *

Email Address *

Is this your first time at our store? *

yes

no

Birthday * +

Pertinent medical/surgical history: *

Please List Any Drug Allergies

Results may take up to 3 treatments

I agree to the risks of this treatment and understand that while the technician is trained and the machine is calibrated but complications can still occur *

I understand and accept the risks

Do you have any of the following Contraindications Contraindications and precautions include: keloid or raised scarring; history of eczema, psoriasis, actinic (solar) keratosis, herpes simplex infections, diabetes, and other chronic conditions; presence of raised moles, warts or any raised lesions in the target area. Absolute contraindications include: scleroderma, collagen vascular diseases or cardiac abnormalities; rosacea or blood clotting problems; active bacterial or fungal infections; immuno-suppression; scars less than 6 months old; and facial fillers used in the past 2 - 4 weeks. Treatment is not recommended for patients who are pregnant or nursing. *

YES

NO

Do you have ANY of these conditions? *

Active acne, especially inflammatory lesions

Active herpes labialis or other localized infection in the treatment area, including warts.

Moderate-to-severe chronic skin diseases such as eczema or psoriasis

extreme keloidal tendencies

Immunosuppressed patients, including patients on chemotherapy

Recent Botox or Injections

None of the above

Have you recieved any of these services in the past 30 days? *

Do you have or have you had any of the following medical conditions that could compromise your skin & or services being offered? Use of Accutane, Adapalen, Isotetinoin, Retin-a, Renova, Alustra, Avita, Tazarotene, Tretinoin, Avage, Differin Sunburned skin, Retinol, Certain medical conditions, Pregnency, Antibiotics, Frequent Tanning or Other medications not listed. These things can make your skin thinner and more sensitive *

no

yes

You answered YES to the question above - Please Explain *

Are you currently under the care of a physician or dermatologist? If so, what for? *

Other conditions which should be approached with caution include psoriasis, bleeding disorders, vitiligo and severe histamine reactions. *

I have a condition listed above

I do not have a condition listed above

Self Fitzpatrick classification *

I Pale white skin, blue/green eyes, blond/red hair Always burns, does not tan

II Fair skin, blue eyes, Burns easily, tans poorly

III Darker white skin, Tans after initial burn

VI Light brown skin Burns minimally, tans easily

V Brown skin Rarely burns, tans darkly easily

VI Dark brown or black skin Never burns, always tans darkly

If you are currently taking isotretinoin (or Accutane as it is commercially known), you should havevstopped taking this 6 months before undergoing laser hair removal treatment. This drug can cause skin sensitivity and this is not beneficial in laser hair removal treatment. *

I am not on accutane

I have taken accutane but have stopped in the last 6 months

Photosensitising drugs and antibiotics can make your skin ULTRA sensitive and possibly can cause a burn during LHR There are a multitude of common drugs, which can also interfere with treatment. Steroids, antibiotics such as tetracyclines and analgesics like ibuprofen are just some such drugs. Why do antibiotics increase photosensitivity? On a structural level, the molecules in these medications can destabilize. If destabilization occurs, chemicals build up in the skin, resulting in increased sun sensitivity and other problems Common Sun-Sensitizing Drugs Antibiotics: doxycycline, tetracycline, ciprofloxacin, levofloxacin, ofloxacin, trimethoprim Antidepressants: doxepin (Sinequan); and other tricyclics; St. John's wort Antifungals: griseofulvin Antihistamine: promethazine, diphenhydramine Antihypertensives (blood pressure drugs): hydrochlorothiazide (also found in some blood pressure medicines: Aldactazide, Capozide), diltiazem (Cardizem) Benzocaine Benzoyl peroxide Cholesterol drugs: atorvastatin, lovastatin, pravastatin, simvastatin Chemotherapy drugs: doxorubicin, flutamide, 5-FU, gemcitabine, methotrexate Diuretics: bumetanide, furosemide, hydrochlorothiazide Hypoglycemics: glipizide, glyburide Neuroleptic drugs: Chlorpromazine, fluphenazine, perphenazine, thioridazine, thiothixene Nonsteroidal anti-inflammatories: celecoxib, ibuprofen, ketoprofen, naproxen, piroxicam Other drugs: dapsone, Para-aminobenzoic acid (PABA), quinidine. PDT Pro photosensitizers: 5-aminolevulinic acid, methyl-5-aminolevulinic acid Retinoids: acitretin, isotretinoin Sulfonamides: sulfadiazine, sulfamethoxazole, sulfasalazine, sulfisoxazole Please list current medications Tetracycline, doxycycline, nalidixic acid, voriconazole, amiodarone, hydrochlorothiazide, naproxen, piroxicam, chlorpromazine and thioridazine *

You answered yes to the question above. Please explain AND let the technicion know verbally. *

I acknowledge that beauty and medi spa treatments, including, but not limited to: Eyelash Exensions, Lash LIfts, skin care, massage, microablation, microdermabrasion, waxing, hair and scalp treatments, nail treatments, electrolysis, facial toning, permanent cosmetics, body treatments, ionization, laser treatments, tattoo removal, vein treatments, brown spot removal, BOTOX, Collagen, Dermal Fillers, PRP Injections, Sclerotherapy, Piercing Mesotherapy, Dermaplaning, and various other beauty procedures is not an exact science and no specific guarantees 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.

On behalf of myself, my heirs, my executors, and my administrators, I 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, skin damage, nerve damage, disability, death, scarring, infection, change in skin pigmentation, allergic reaction, eye damage, change or damage to my vision, muscle damage, and increased hair growth. I understand that even though precautions may be taken in my treatment, not all risks can be known in advance.

Given the above, I 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, indemnify, hold harmless and release from any and all liability, costs of litigation and any other costs of every kind and nature, the company and the individual that provided my treatment, the insured, their insurance company, and any additional insureds, as well as any officers, directors, or employees of the above companies for any injury, property damage, condition or result, known or unknown, that may arise as a consequence of any treatment that I receive.

The release contained herein will be onstrued to apply to the greatest extent permitted by law and, if permitted by law, will apply even if any such injury or damage is caused in whole or in part by the released parties' own negligence or the negligence or willful conduct of any other individual.

In the event any provision of this agreement is found to be legally invalid or unenforceable for any reason, all remaining provisions will remain in full force and effect. In the event any provision of this document is found by a court of competent jurisdiction to exceed the limits permitted by any applicable law or to be invalid or unenforceable as written, such court (s) may exercise its discretion in reforming such provision(s) to the extent necessary to make it reasonable and enforceable. 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. It is understood that any such arbitration will be final and binding and that by agreeing to arbitration, the dersigned is waiving their rights to seek remedies in court, including the right to a jury trial. The undersigned waives, to the fullest extent permitted by law, any right they may have to a trial by jury in any legal proceeding directly or indirectly arising out of or relating to this agreement whether based in contract, tort, statute (including any federal or state statute, law, ordinance, or regulation), or any other legal theory.

The insured agrees that this contract will be governed and construed in occordance with the laws of the state of South Dakota and that all actions of any kind whatsoever will be heard, governed, arbitrated, and restricted to the venue of the County of Meade County, South Dakota. The ndersigned also agrees and stipulates that they will be responsible for any legal, or other costs of any kind, incurred by the insured or their insurance company in defense of this agreement should the undersigned challenge its enforceability. The client indicated below also agrees to forever hold harmless and release from any and all liability, claims, or demands of any kind or nature the insured, and their insurance company for the transmission of any disease, condition, injury or illness
they may allege to have contracted or been exposed to as the result of any treatment, person, or visit at the insured's location or the location of treatment. I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect my treatment. In consideration for treatment received, I hereby grant permission to the individual or company that provided my treatment to use any photographic treatment records for the purposes of clinical and statistical studies, advertising, or promotion without any additional compensation to me.

I certify that the information I have provided above is accurate to the best of my knowledge. And I agree to the terms of service. *

clear

ENJOY YOUR SERVICE! Thank you for coming - B. Sweet

Chemical Peel	IPL treatment	Microneedling
Botox or fillers	Laser facial treatments	Laser Hair Removal
Basic facial	None of the above