B. SWEET SERVICE WAIVER & CONCENT

Is this your first time at our store? *
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What service are you receiving today? *
Have you recieved the SELECTED MED-SPA services at our stores? *
Do you have any changes to your medical history since your last visit? *
Do you have or have you ever had any of the following conditions: *
Pertinent medical/surgical history: *
Medication History *
Are you currently using or do you have a history of tobacco use? *
Are you currently using or do you have a history of illegal drug use? *
Have you had any of these services in the past 2 weeks? *
PATIENT CONSENT FOR PHYSICIAN TO USE OR DISCLOSE HEALTH CARE INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE. *
HIPPA I UNDERSTAND THAT MY HEALTH INFORMATION IS PRIVATE AND CONFIDENTIAL. I UNDERSTAND THAT B. Sweet WORKS VERY HARD TO PROTECT MY PRIVACY AND PRESERVE THE CONFIDENTIALITY OF MY PERSONAL HEALTH INFORMATION. I UNDERSTAND THAT SIGNING THIS DOCUMENT MEANS THAT B. SWEET MAY USE AND DISCLOSE MY PERSONAL HEALTH INFORMATION TO HELP PROVIDE HEALTH CARE TO ME, TO HANDLE BILLING AND PAYMENT, AND TO TAKE CARE OF OTHER HEALTH CARE OPERATIONS. FAILURE TO SIGN THIS CONSENT MAY RESULT IN THE PHYSICIAN DECLINING TO TREAT ME. UNDER THE TERMS OF THIS CONSENT, I CAN ASK B. SWEET TO RESTRICT HOW MY PERSONAL HEALTH INFORMATION IS USED OR DISCLOSED TO CARRY OUT TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS. I UNDERSTAND THAT B. SWEET / Beauty Bar Med-Spa DOES NOT HAVE TO AGREE TO MY REQUEST. IF HE DOES AGREE TO MY REQUEST, I UNDERSTAND THAT HE WOULD FOLLOW THE AGREED LIMITS. I UNDERSTAND THAT I HAVE THE RIGHT TO CANCEL THIS CONSENT IN WRITING AT ANY TIME. IF I DO CANCEL THE CONSENT, I UNDERSTAND THAT B. Sweet / Beauty bar Med-spa MAY HAVE ALREADY USED OR DISCLOSED INFORMATION ABOUT ME AND CANCELING THIS CONSENT WOULD NOT AFFECT THE INFORMATION ALREADY USED OR DISCLOSED. I MAY CANCEL THIS CONSENT AT ANY TIME BY DOING THE FOLLOWING: WRTING, SIGNING, AND DATING A LETTER TO [INSERT PROVIDER NAME HERE] THAT SAYS I WANT TO REVOKE MY CONSENT TO AUTHORIZE THE USE AND DISCLOSURE OF MY PERSONAL HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPTIONS. I UNDERSTAND IF I CANCEL THIS CONSENT, B. SWEET / Beauty Bar Med-SpaIS NOT OBLIGATED TO PROVIDE FURTHER HEALTH CARE SERVICES TO ME. *
TO GIVE CONSENT TO DISCLOSE HEALTH CARE INFORMATION TO SOMEONE OTHER THAN THE PATIENT, PLEASE WRITE THEIR NAME BELOW: (E.G. FAMILY MEMBER, CARETAKER)
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IPL
 
I understand light can be used effectively to destroy targets located in the skin with minimum damage to the surrounding tissues. Light is used to lighten, fade or remove photo-damaged skin in a nonablative manner, a procedure known as photo
rejuvenation. Visible sings of photo damage include wrinkling, enlarged pores, course
skin texture, and pigment alterations.

Photo-therapy, despite its high levels of efficacy and safety, is not free of side effects.

1. Erythema (redness) and edema (swelling) of the treated area can occur but usually subsides within a few hours but can last up to seven days or longer.

2. Irritation, itching, and/or a mild burning sensation or pain similar to sunburn may occur within 48 hours of treatment.

3, Pigmentary changes such as hyper pigmentation and hypo pigmentation of the skin in the treated areas can occasionally occur. Mostly it is transient, lasting up to six months, but in rare cases it can be permanent. Most cases of hypo- or hyper-pigmentation occur in people with darker skin or when the treated area has been exposed to sunlight before or after treatment. Occasionally these pigmentary changes occur despite appropriate
protection from the sun.

4. Scarring, which can be hypertrophic or even keloid, can occur.

5. Other known complications of this procedure include blisters, reddening, pinpoint pitted scars, bruising, superficial crusting, burns, pain, and infections.

These side effects are usually temporary, lasting from five to ten days but can be permanent as well.

Keep in mind:

The skin at or near the treatment site may become fragile. If this happens, makeup should
be avoided and the area should not be rubbed, as this might tear the skin. A blue-purple
bruise may appear on the treated area, which might last from five to fifteen days. As the
bruise fades, there may be rust-brown discoloration of this skin, which fades in one to
three months or longer.

Additionally, there is a known and expected loss of hair in the treated areas. In a very small percent of people there is new hair growth in the surrounding areas being treated.

Even though appropriate measures are taken to reduce side effects, they cannot be completely eliminated in every case.

I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume these risks.

There may be other treatment options, such as injections, other types of lasers/light sources or peels. With this in mind, I am choosing this non-invasive treatment for vascular and/or pigment lesions and other indicated skin conditions.

Eye damage can occur from the light and therefore protective eyewear must be worn during all phototherapy sessions.


Example of extreme freckle removal with zebra stripping

Pigmentary changes such as hyper pigmentation and hypo pigmentation of the skin in the treated areas can occasionally occur. Mostly it is transient, lasting up to six months, but in rare cases it can be permanent. Most cases of hypo- or hyper-pigmentation occur in people with darker skin or when the treated area has been exposed to sunlight before or after treatment. Occasionally these pigmentary changes occur despite appropriate protection from the sun.
 
When we are performing “extreme” freckle removal, then this is what mostly occurs. Please expect it. If we were performing the more typical and low energy attempts at freckle removal, we wouldn’t get this, but we are aiming for maximal results, and this is part of the process. Tiger striping is the appearance of the  untreated areas between laser pulses. If less powerful settings are used then tiger striping is less common and less severe. It will only occur when results are obvious or there is significant background sun damage. It is less obvious when patients don’t have a lot of background sun damage.

Example of light IPL burn

Other known complications of this procedure include blisters, reddening, pinpoint pitted scars, bruising, superficial crusting, burns, pain, and infections.
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 *
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. *
Do you have ANY of these conditions? *
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 *
Other conditions which should be approached with caution include psoriasis, bleeding disorders, vitiligo and severe histamine reactions. *
Self Fitzpatrick classification *
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. *
Do you have any skin conditions or alergies that your esthetician should be aware of prior to performing your service? Please explain AND let the technician 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. *
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ENJOY YOUR SERVICE! Thank you for coming - B. Sweet

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