LIABILITY WAIVER AND HOLD HARMLESS, AGREEMENT

This Liability Waiver and Hold Harmless Agreement (the “Agreement”) is entered into between Fotona, LLC (“Fotona”) and (the “Customer’s Client”). Fotona and the Customer’s Client are sometimes referred to herein, collectively, as the “Parties.” *
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AGREEMENT

RECITALS WHEREAS, Fotona desires that its customers – purchaser and users of its products, devices, and procedures – are highly trained and highly competent to use Fotona’s products, devices, and procedures to achieve the best outcome(s) for its customers’ clients/patients; WHEREAS, Fotona engages training doctors to train new and existing customers (“Trainee or Trainees”) on the EndoTight procedure using Fotona’s products, devices, and/or procedures (the “Procedure”); WHEREAS, Trainees desires to participate in training with a training doctor for the Procedure (the “Training”); WHEREAS, Customer’s Client wishes to serve as the patient for a Trainee; WHEREAS, a training doctor, and not Fotona, will perform the Training; and WHEREAS, Trainee, and not Fotona, will perform the Procedure. NOW, THEREFORE, in consideration of participating in the Training, receiving the Procedure, and the promises and obligations contained herein, the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows: *
Liability Waiver and Hold Harmless. THE CUSTOMER’S CLIENT AGREES TO HOLD HARMLESS FOTONA, INCLUDING ITS OFFICERS, MANAGERS, EMPLOYEES, AGENTS, AND REPRESENTATIVES, FROM AND WAIVES ANY AND ALL CLAIMS, DISPUTES, LAWSUITS, ACTIONS, INJURIES, LIABILITY, COMPENSATION, DAMAGES, COSTS, AND/OR EXPENSES (INCLUDING, WITHOUT LIMITATION, ATTORNEY’S FEES), RELATED TO, RESULTING FROM, OR ARISING OUT THE TRAINING, WHICH INCLUDES, BUT IS NOT LIMITED TO CLAIMS OF NEGLIGENCE; CLAIMS RELATED TO CUSTOMER’S CLIENT’S PARTICIPATION IN THE TRAINING, SUCH AS NEGLIGENCE; AND/OR ANY ACT OR OMISSION, INCLUDING NEGLIGENCE BY FOTONA AND/OR ITS OFFICERS, MANAGERS, EMPLOYEES, AGENTS, AND REPRESENTATIVES. *
Fees and Costs. In any action related to, resulting from, or arising out of this Agreement, the prevailing Party shall be entitled to reimbursement for its reasonable attorney’s fees and all costs at the trial and appellate levels. *
Governing Law, Jurisdiction, and Venue. The Parties agree that this Agreement and any disputes related to, resulting from, or arising out this Agreement shall be governed by and construed in accordance with the laws of the State of Texas, without regard to any conflicts of law provisions, principles, or rules that would require or permit the application of the laws of any jurisdiction other than those of the State of Texas. Each Party to this Agreement consents to the jurisdiction of all state and federal courts sitting in Dallas County, Texas, agrees that venue for any such action shall lie exclusively in such courts, and agrees that such courts shall be the exclusive forum for any legal actions related to, resulting from, or arising out of this Agreement and/or any disputes related to, resulting from, or arising out this Agreement. *
Waiver of Breach. The waiver by any Party of a breach of any provision of this Agreement by the other Party shall not operate or be construed as a waiver of any subsequent breach or violation thereof. *
Entire Agreement. This writing represents the entire Agreement and understanding of the Parties with respect to the subject matter hereof and supersedes all prior agreements, representations, and understandings of the Parties in connection therewith. *
Incorporation of Recitals. The Parties incorporate each of the above recitals as part of this Agreement. *
Binding Effect. This Agreement shall be binding upon and inure to the benefit of the Parties hereto and their respective representatives, successors, and assigns. The Parties represent, warrant, and acknowledge that this Agreement has been executed and delivered by all Parties for fair and adequate consideration under all applicable laws and that this Agreement is valid, binding, and enforceable in accordance with its terms. *
Severability. If any provision of this Agreement shall be or becomes illegal or unenforceable, in whole or in part, for any reason whatsoever, the remaining provisions shall nevertheless be deemed valid, enforceable, and binding. *
Ambiguity. The Parties arrived at the terms and provisions of this Agreement through mutual negotiations with the assistance of their respective attorneys. Accordingly, no ambiguity in this Agreement that may arise in the future shall be construed against or adversely to any Party. *
Counterparts. The Parties agree that this Agreement may be executed in two or more counterparts, each of which shall constitute an original and binding copy of this Agreement. Executed photocopies of this Agreement shall be as binding as the original. *
Amendment. Neither this Agreement, nor any provisions of this Agreement, may be waived, rescinded, amended, modified, or terminated, except by an instrument in writing signed by all Parties. *
No Legal Effect of Heading Titles. Paragraph titles or heading titles contained in this Agreement are for reference purposes only and are not intended to affect in any way the meaning or interpretation of this Agreement. *
IN WITNESS WHEREOF, and intending to be legally bound hereby, Fotona, LLC has executed the foregoing Liability Waiver and Hold Harmless Agreement. Fotona, LLC (“Fotona”) *
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Do you have any of the following in your body? If you have any of these metals please inform your service provider. *
Do you have or have you ever had any of the following conditions: *
Pertinent medical/surgical history: *
Birth control method: *
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? *
Please describe your alcohol consumption : *
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. *
I have recieved the HIPPA information *
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for no monetary consideration hereby grant B. Sweet / Beauty Bar Medspa and Fotona LLC, consent for photography, filming, videotaping, audio recording and/or being quoted in media or printed materials (including social media sites) and hereby authorize the release of such. I agree that Fotona reserves the right to crop and edit the photographs, recordings and/or quotes to use them for any purpose consistent with Fotona’s missions. These uses include, but are not limited to medical research, or science including medical seminars or journal articles, during in- office patient consultations, exhibitions, videos, reprints, reproductions, publications, advertisements, broadcasts, electronic media activities (including the internet) and any promotional or educational materials in any medium now known or later developed, in perpetuity. By signing and dating this document I authorize Fotona to edit and/or share the media mentioned above in order to show the benefits and results of the medical and/or aesthetic procedure. I understand that Fotona will not use my name in any promotional materials. Your name/identifying information will not be revealed. I understand that, by granting this authorization, I am improving patient healthcare and patient education, which constitutes adequate consideration for this authorization. I acknowledge that I have read and understood the terms of this release. *
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CONSENT FOR TEXT MESSAGING OF HEALTH INFORMATION 1. CONSENT TO RECEIVE TEXT MESSAGES By providing your mobile phone number and opting into text messaging services, you consent to receive health-related information, including but not limited to appointment reminders, treatment updates, and other relevant communications directly to your mobile phone via text message. 2. NATURE OF COMMUNICATIONS Text messages may contain sensitive health information, including details related to your medical care, appointment schedules, and other pertinent information regarding your treatment or health status. 3. CONFIDENTIALITY AND SECURITY While every effort will be made to ensure the confidentiality and security of your information, text messaging is not a fully secure method of communication. B. Sweet will use reasonable measures to protect the privacy of the information transmitted but cannot guarantee that text messages will be free from unauthorized access. 4. WITHDRAWAL OF CONSENT You may withdraw your consent to receive text messages at any time by notifying B. Sweet in writing or by contacting our office directly. Withdrawal of consent may result in the discontinuation of text messaging services. 5. ACKNOWLEDGEMENT AND ACCEPTANCE By providing your mobile phone number and agreeing to receive text messages, you acknowledge that you understand the nature of the communications you will receive, the potential risks involved, and the terms under which your health information may be sent to you via text message. 6. LIABILITY B. Sweet, its affiliates, employees, and agents shall not be liable for any unauthorized access to or interception of text messages, or for any damages arising from the use of text messaging services, including but not limited to, any loss or misinterpretation of health information. By continuing with the provision of your mobile phone number and agreeing to receive text messages, you confirm that you have read, understood, and accepted the terms and conditions outlined in this consent form. ACKNOWLEDGEMENT AND CONSENT REGARDING THE USE AND DISCLOSURE OF HEALTH INFORMATION 1. ACKNOWLEDGEMENT OF PRIVACY AND CONFIDENTIALITY I acknowledge that my health information is private and confidential. I understand that B. Sweet is committed to safeguarding my privacy and preserving the confidentiality of my personal health information. 2. CONSENT TO USE AND DISCLOSE HEALTH INFORMATION By signing this document, I consent to B. Sweet's use and disclosure of my personal health information for the purposes of providing health care services to me, handling billing and payment, and conducting other health care operations. I understand that my failure to sign this consent form may result in B. Sweet declining to provide treatment. 3. REQUEST FOR RESTRICTIONS Under the terms of this consent, I have the right to request B. Sweet to impose restrictions on how my personal health information is used or disclosed for treatment, payment, or health care operations. I acknowledge that B. Sweet is not obligated to agree to such restrictions. If B. Sweet does agree to my request, I understand that they will adhere to the agreed-upon limits. 4. RIGHT TO REVOKE CONSENT I understand that I have the right to revoke this consent in writing at any time. Should I choose to cancel this consent, I recognize that B. Sweet may have already used or disclosed my information, and revoking consent will not affect information that has already been used or disclosed. To cancel this consent, I must provide a written, signed, and dated letter to [Insert Provider Name Here] indicating my desire to revoke authorization for the use and disclosure of my personal health information for treatment, payment, and health care operations. 5. IMPACT OF CANCELLATION I understand that if I cancel this consent, B. Sweet is not obligated to provide further health care services to me. By signing this document, I confirm that I have read, understood, and agreed to the terms and conditions outlined herein. *
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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1. I hereby authorize B. SWEET LASER TECHNICIANS, or NP and such assistants as may be selected, to perform the following procedure or treatment:
 
2. I recognize that during the course of the procedure and medical treatment or anesthesia, unforeseen
conditions may necessitate different procedures than those above. I therefore authorize the above physician and assistants, or designees to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time the procedure is begun.
 
3. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications, injury.
 
4. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.
 
 
IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
b. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
c. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED
I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS. I AM
SATISFIED WITH THE EXPLANATION.

INFORMED CONSENT FOR GENERALIZED LASER TREATMENTS

1. Nature and Purpose of Treatment:

I, the undersigned, hereby authorize B. Sweet aesthetics staff and/or such assistants as may be designated, to perform laser treatment on me. 

2. Risks and Potential Complications:

I acknowledge and understand that the laser treatment, like all medical procedures, carries certain risks and potential complications, including but not limited to:

  • Erythema (redness), edema (swelling), and localized discomfort.
  • Temporary or permanent changes in skin pigmentation, including hyperpigmentation and hypopigmentation.
  • Formation of blisters, scabbing, or crusting.
  • Risk of scarring or keloid formation, particularly in individuals predisposed to such conditions.
  • Risk of infection at the treatment site.
  • Possible allergic reactions to post-treatment skincare products.

I understand that while complications are infrequent, they can occur, and the results may vary depending on individual factors.

3. Alternatives to Laser Treatment:

I have been informed of alternative treatments available for my condition, which may include but are not limited to, other laser therapies, chemical peels, topical medications, or no treatment at all. I acknowledge that these alternatives have been explained to me, and I understand the benefits and risks associated with each option.

4. Contraindications and Disclosures:

I have disclosed to the practitioner all pertinent aspects of my medical history, including any history of keloid formation, photosensitivity disorders, or any other conditions that may contraindicate this procedure. I further acknowledge that I am not currently pregnant or breastfeeding, nor am I taking any medications or supplements that may adversely affect the treatment.

5. Pre- and Post-Treatment Instructions:

I have been provided with and understand the pre-treatment instructions, which include but are not limited to avoiding sun exposure and certain medications. I also acknowledge receipt and understanding of post-treatment care instructions, including avoiding sun exposure, applying prescribed ointments, and adhering to follow-up care protocols.

6. Consent to Photographic Documentation:

I consent to the taking of photographs before, during, and after the treatment for the purpose of medical records, education, or marketing, with the understanding that my identity will remain confidential unless otherwise agreed upon.

7. Acknowledgment of Understanding:

I acknowledge that I have had the opportunity to ask questions regarding the nature, purpose, risks, and alternatives to the Pico laser treatment. I confirm that all my questions have been answered to my satisfaction.

8. Voluntary Consent:

By signing below, I hereby give my voluntary consent to undergo laser treatment as proposed. I understand that this consent form does not constitute a guarantee or warranty of the outcome of the treatment.

9. Signature:

I have read and fully understand the contents of this consent form. I am signing this form voluntarily and affirm that I am of sound mind and not under the influence of any substance that could impair my decision-making.

10. Results & expectations

Potential and common side effects that may occur with Picosecond & FOTONA LASER treatments:

• DISCOMFORT may be minimal to moderate. Some areas are more sensitive than others. Topical anesthetic is available for purchase if required. Certain laser treatments include a prescription grade topical anesthetic or can be added on for an additional fee.

• INFLAMMATION which may include irritation, itching, pain, bruising, flaking, ingrown hairs, typically subside/fade in 5-7 days

• ERYTHEMA (redness) and mild to moderate “sunburn” like effects may last for a few hours to 2-5 days

• EDEMA (swelling) of the skin around the treatment site may last 2-5 days, but can be reduced with regular application of a cold gel pack

• PUSTULES or PIMPLES may develop in the first few days following treatment and gradually subside

• TEXTURE CHANGES - Transient texture changes often occur, but usually resolve with time

• BLISTERING, SCABBING or CRUSTING may occur and usually take 4-10 days to heal.

• PETECHIAE may be present after treatment and may last 3 - 5 days. 

• FRECKLES/PIGMENT – Existing freckles/pigment in the treated area may temporarily or permanently disappear

• COINCIDENTAL HAIR REMOVAL – There is a possibility of coincidental hair removal when treating pigmented or vascular lesions in hair-bearing areas

SKIN EXPECTATIONS FOTONA

1. Directly after skin will be pink, feel hot & possibly have pinpoint bleeding

2. Day 1-2 moisturize, the skin will be dry and rough to the touch

3. Day 3-5 skin will feel tight and like sandpaper. Dry & wrinkly looking. Don't worry continue to moisturize. At day 5, use a gentle exfoliate to slough excess skin.

4. Results are not immediate - the skin will improve over time. Be patient, best results at 2 to 3 months.

 

I have read and understand the above informed consent. The informed consent for generalized laser treatments outlines the following key points: Nature of Treatment: The patient authorizes the staff to perform laser treatment, with the understanding of its purpose. Risks and Complications: Possible risks include redness, swelling, pigmentation changes, blistering, scarring, infection, and allergic reactions. Although complications are rare, they can occur. Alternatives: Other treatments such as chemical peels, topical medications, or no treatment are explained as alternatives. Contraindications: The patient confirms that they have disclosed relevant medical history and are not pregnant, breastfeeding, or taking contraindicated medications. Pre- and Post-Treatment Instructions: Patients are advised to avoid sun exposure and follow skincare protocols before and after treatment. Consent for Photographs: The patient consents to photos for medical or educational purposes, ensuring anonymity. Acknowledgment: The patient confirms they understand the procedure and have had their questions answered. Voluntary Consent: The patient consents to treatment without any guarantee of results. Results and Expectations: Side effects may include discomfort, redness, swelling, blisters, and potential skin texture changes. Results vary, with improvement seen after multiple treatments and over time. Specific expectations are outlined for different treatments (Pico laser, Fotona laser, vein treatment), including skin reactions, post-care, and recovery time. Overall Recovery: The patient can generally return to normal activities shortly after treatment, with results developing gradually over weeks or months. *
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Disclaimer: Informed consent documents are used to communicate information about the proposed treatment of a disease or condition along with disclosure of risks and alternative forms of treatment. The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed consent documents should not be considered all inclusive in defining other methods of care and risks encountered. Your physician may provide you with additional or different information which is based on all the facts in your particular case and the state of medical knowledge. Informed consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve. It is important that you read the above information carefully and have all of your questions answered before signing the consent. *
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