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Terms and Consent Form

I, (further addressed as ‘the client’), born on / / , authorize CAROLINA PINTOS THERAPY, PLLC, and its team, employees, and/or associates to treat me (the client) and to use any needed machine to perform the desired treatment(s) and/or result(s) defined by me (the client). This document serves as a witness that CAROLINA PINTOS THERAPY, PLLC, and its team, employees, and/or associates have been presented with the below client information and do not have any further knowledge of any complications beyond what was provided by the client.

I, the client, understand that there are certain risks associated with this/these treatment(s) and they include but are not limited to the following: Bruising, abrasion, swelling, Lymphorrhea, and temporary redness to the surface of the skin.

I, the client, also agree to inform CAROLINA PINTOS THERAPY, PLLC, immediately if any adverse effects occur post or during the treatment(s).

I, the client, have been made aware of the risks and I accept these terms and conditions as part of my treatment. CAROLINA PINTOS THERAPY, PLLC, and its team, employees, and/or associates accept NO liability for any side effects. By accepting this, I, the client, agree to the terms and conditions and in the event of any injury, I, the client, or any of my representatives, waive the right to pursue any kind of claim(s), demand(s), or lawsuits, damages, and liabilities in law or in equity, to gain compensation in the present or in the future.

I, the client, agree to arbitration as a way to limit litigation costs and keep disputes confidential.

I, the client, have been informed about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have.

I, the client, fully understand the treatment conditions and procedure. I agree to pay for the treatment services and understand that there will be NO refunds for any performed services. This consent form and cost cover the selected treatments only. Additional treatments can be added to this consent form and will be charged as per the clinic price list, including a single session.

I, the client, certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction.

I, the client, agree to photographic documentation of the treated area prior to and post-treatment(s).

I, the client, acknowledge that my treatment will be done during a pandemic and that while CAROLINA PINTOS THERAPY, PLLC, and its team, employees, and/or associates comply with the State Health Department and the Center for Disease Control and Prevention Infection Control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees that you will not be infected.

I, the client, certify that I have read the entire informed consent and I agree to all its provisions.

Client Information

Name:
Gender:
DOB:
Treatment:
Focus Area:
Surgeries:
Had Fat Injection:
Cosmetic Implants:
Metalic Implants:
Treatment Reaction(s):
Hormonal Therapy:
Tattoos:
Sunbathe:
Allergies and Skin Sensitivities:
Condition, Disease, or Situation:
Have you had any flu symptoms in the last 14 days:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

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January 28, 2020 12:33 pm CST

Terms and Consent Form Uploaded by Carolina Miranda - [email protected] IP 2600:387:f:5718::3