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Testimonial Consent Form

I grant to The Primping Place, its representatives, employees and Neurotris the right to take photographs, videos and/or testimonials of me and my property in connection with before and after photographs, videos and/or testimonials used to promote cosmetic treaments. I authorize The Primping Place, its assigns, transferees and NeurotrIS to copyright, use and publish the same in print, electronically and digitally.

I agree that The Primping Place and Neurotris may use such photographs, videos and/or testimonials of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, social media and Web content. I hereby hold harmless and release The Primping Place and Neurotris from all claims, demands and causes of action which I may have by reason of this authorization. 

 

 

Contraindications: 

-Active Cancer

-Cardiac Pacemakers

-Seizures

-Metal Plates/Implants

-Pins in Area of Treatment

-Diabetes (Physician apporval needed)

-Surgery Within 6 Months

-Phlebitis/Thrombosis

-Any Blood Thinners

-Spinal Problems

-Mental Instability

-Epilepsy

-Pregnancy/Breast Feeding

-Broken Blood Vessel on Surface of Skin

-Skin Irritation

 

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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 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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