Ultrasound Cavitation and Radio Frequency Treatment Agreement Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Are you over 18 years old? * Yes No Emergency Contact * Name and Phone Number Mark for "Yes" * By checking box(es) below, I am saying "Yes" to having this/these conditions. Pregnant/Nursing Transplant Hemophilia Epileptic Thrombosis Tumor/Cancer On Antibiotics Cardiac/Vascular Condition Kidney Disease/Failure Unhealed Wound Pacemaker/Electronic Device Metal/Plastic Implant On Steroids Being treated with Anticoagulants History of Internal Bleeding Infectious/Communicable Disease Abdominal Surgery within 6 months High/Low Blood Pressure or Diabetes Any condition with the Liver or Lymphatic System Currently Menstrating None of the above Explain any "Yes" answers: * Are you allergic to coconut or coconut oil? * Yes No Please explain any other current medical conditions or allergies. * By printing my name below, I affirm all the above information is true to the best of my knowledge. * Date * MM DD YYYY Disclosure This treatment is a process and subsequent visits may be necessary to achieve the desired results. Subsequent visits are subject to additional charges per visit which depend on the amount of work needed. Actual results vary from person to person and Makana Massage does not guarantee any specific result. The Ultrasound Cavitation treatment carries with it possible health complications and consequences, which include but might not be limited to the risk of kidney failure, liver failure, pacemaker failure, birth defect, miscarriage, thyroid damage, damage to the ovaries, lactation complications, hyper-triglyceridemia, hypercholesterolemia, pancreatitis, infection, scarring and/or allergic reaction to any products used, excessive thirst, dehydration, nausea. The Ultrasound Cavitation treatment includes, but is not limited to, the use of high-power low-frequency ultrasound cavitation which uses 30KHz frequency ultrasound to penetrate the skin and assist with the breakdown of fat cells by creating micro-bubbles that increase the pressure around the adipocyte and force it to implode, thus breaking down adipocyte’s cell membrane. Before and After Care Instructions must be followed explicitly, whether given in writing or orally. Failure to follow pre and post care instructions may compromise the results of the treatment. Pictures Before, during, and after pictures or videos may be taken to document the treatment. These pictures or videos become Makana Massage sole property and may only be used for its legitimate business purposes. Release I recognize that there are certain inherent risks associated with the above-described treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release and forever discharge Makana Massage (including its officers, members, owners, employees, and agents) from all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether on account of myself, Makana Massage or other third parties, or in any way arising out of the above-described treatment I have requested to perform. It is the intention of the parties that this agreement binds all parties whose claims may arise out of or relate to the treatment or services provided by Makana Massage including any spouse or heirs of the client/patient and any children, whether born or unborn. Any legal or equitable claim that may arise from participation in the treatment shall be resolved under Utah law. I agree to indemnify, hold harmless and defend Makana Massage (including its officers, members, owners, employees, and agents) against all third-party claims, causes of action, damages, judgments, costs, or expenses, including attorneys’ fees and other litigation costs, which may in any way arise from the above described treatment I have requested Makana Massage perform. Arbitration It is understood that any disputes arising as to malpractice of the Ultrasound Cavitation treatment shall be decided by a neutral arbitrator. Any arbitration proceeding will be governed by Colorado’s arbitration statute, the fees for the arbitrator will be split pro-rata among the parties and each party will be responsible for their own attorney’s fees and costs. Any action to collect fees from the client/patient for the treatments performed may be brought in any court located in Colorado and the prevailing party in such collection action shall be entitled to recover its reasonable attorney’s fees and costs. Filing of any action in any court to collect any fee from the client/patient shall not waive the right to compel arbitration of any malpractice claim. Financial Policy We are honored to be of service to you. This is to inform you of our billing requirements and financial policy. Please be advised that payment for all services is due at the time services are rendered. We require full payment for the visit prior to being seen by our cavitation/or RF technician. We accept Venmo, Credit Card, Debit and Cash. In the event this account is referred to an agency for collections you agree to be responsible for all returned fees including any collections costs, collection’s agency and/or attorney’s fees used for collection. By signing this agreement, I confirm that I am over the age of 18, I understand that the Ultrasound Cavitation procedure is permanent, that such procedure has possible adverse consequences, and that the procedure is for cosmetic purposes only. * I certify that I have read the above paragraphs; fully understand this consent and procedure form and hereby consent to the indicated procedure(s). This means that I accept full responsibility for these and/or any other complications which may arise or result during or following the Ultrasound Cavitation procedure which is to be performed at my request according to this agreement and I hereby agree to arbitration of any malpractice claim. I further understand that by signing this agreement, I surrender certain legal rights. First Name Last Name Thank you!
