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Client Treatment Consent and Release

I acknowledge that beauty treatments, the practice of skin care, and the practice of massage, including, but not limited to, microablation, microdermabrasion, waxing, electrolysis, facial toning, permanent cosmetics, body treatments, ionization, laser treatments, tattoo removal, vein treatments, brown spot removal, BOTOX, Collagen, Dermal Fillers, Sclerotherapy, Mesotherapy, Dermaplaning, 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, scarring, infection, change in skin pigmentation, allergic reaction, 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, hold harmless 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 effect 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. 

Client Signature


Date: August 26, 2019

Model Release In consideration for treatment received, I herby 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. 

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First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

IAME CLIENT HEALTH HISTORY 

All questions contained in this questionnaire are strictly confidential.


How did you hear about IAME? *

IF YOU HAVE A HEART PROBLEM YOU MAY NOT RECEIVE A TREATMENT

CONFIDENTIAL HEALTH INFORMATION
Are you currently under the care of a physician for your skin?*
No
Yes
Have you ever seen a physician for your skin?*
No
Yes
Are you currently taking Accutane®?*
No
Yes
Have you ever taken Accutane®?*
No
Yes

Date of last dose:
Do you currently use Retin-A ®?*
No
Yes
Do you currently use Hydroquinone?*
No
Yes
Have you ever used a topical fluorouracil preparation on your skin? (Carac®, Efudex ®, Fluoroplex®)*
No
Yes

Date:

Body Location:
Have you any known Allergies to anything?*
No
Yes: see box below

If yes, please list all allergies: (include medications, aspirin, food, fabrics, latex, etc.)

ABILITY TO HEAL

Does your skin appear fragile or burn easily?*
No
Yes
Do you have any problems healing from a cut or burn?*
No
Yes
Do you ever use depilatories or waxes on your face?*
No
Yes

If yes date last used:
Have you ever had a cold sore?*
No
Yes

If yes date of last one?

Please list all oral medications you currently take:(Include hormones, birth control pills, antibiotics, tranquilizers, anti-depressants, diuretics, etc.)

Do you have any health problems? Please explain:
Skin Condition
Rosacea
Acne
Dehydrated
Lax/Loose
Millia
Pigment
Sun damage
Broken capillaries
Other

If Other please specify
Skin Type
Normal
Dry
Oily
Combo
Sensitive
How noticeable are your pores?*

My last skin treatment was:

Date received:

Current skin products & brand used:
First Client's Signature*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

IAME CLIENT HEALTH HISTORY 

All questions contained in this questionnaire are strictly confidential.


How did you hear about IAME? *

IF YOU HAVE A HEART PROBLEM YOU MAY NOT RECEIVE A TREATMENT

CONFIDENTIAL HEALTH INFORMATION
Are you currently under the care of a physician for your skin?*
No
Yes
Have you ever seen a physician for your skin?*
No
Yes
Are you currently taking Accutane®?*
No
Yes
Have you ever taken Accutane®?*
No
Yes

Date of last dose:
Do you currently use Retin-A ®?*
No
Yes
Do you currently use Hydroquinone?*
No
Yes
Have you ever used a topical fluorouracil preparation on your skin? (Carac®, Efudex ®, Fluoroplex®)*
No
Yes

Date:

Body Location:
Have you any known Allergies to anything?*
No
Yes: see box below

If yes, please list all allergies: (include medications, aspirin, food, fabrics, latex, etc.)

ABILITY TO HEAL

Does your skin appear fragile or burn easily?*
No
Yes
Do you have any problems healing from a cut or burn?*
No
Yes
Do you ever use depilatories or waxes on your face?*
No
Yes

If yes date last used:
Have you ever had a cold sore?*
No
Yes

If yes date of last one?

Please list all oral medications you currently take:(Include hormones, birth control pills, antibiotics, tranquilizers, anti-depressants, diuretics, etc.)

Do you have any health problems? Please explain:
Skin Condition
Rosacea
Acne
Dehydrated
Lax/Loose
Millia
Pigment
Sun damage
Broken capillaries
Other

If Other please specify
Skin Type
Normal
Dry
Oily
Combo
Sensitive
How noticeable are your pores?*

My last skin treatment was:

Date received:

Current skin products & brand used:
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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