Signed in as:
filler@godaddy.com
Signed in as:
filler@godaddy.com
1. Realistic expectations, NO guarantee, result vary:
Be advised that result may vary based upon variables, age, diet, metabolism and other personal factors outside of the control of Mary's as a company. We will strive to assist you based on your predetermined factors, to provide the best results, however, we do not guarantee any outcome.
2. I'm not a doctor:
I'm NOT a Doctor. I do not diagnose and do not provide any prognosis on any preexisting or potential medical conditions. If you have a chronic medical condition, have a metal plate, a pacemaker, hearing aid, hormone pellets, medical devices implanted, diabetes, cancer, thyroid problems, high blood pressures, cardiovascular conditions, skin diseases, pregnant or nursing consult with your health care provider before scheduling your appointment.
Disclosure - This treatment is a process and subsequent visits my be necessary in order to achieve the desired results. Subsequent visits are subject to additional charges per visit depending on the amount of work needed.
Actual results vary from person to person and Mary's Body Shaping does not guarantee any specific results. The Ultrasonic 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 defects, miscarriage, thyroid damage, damage to the ovaries, lactation complications, elevated triglycerides, elevated cholesterol, pancreatitis, infection, scarring and/or allergic reaction to any products used, excessive thirst, dehydration, nausea.
The Ultrasonic treatment includes, but is not limited to, the use of high-power low-frequency ultrasound cavitation, which uses 40KHz 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, thru breaking down adipocyte’s cell membrane.
After Care - After care instructions must be followed explicitly, whether given in writing or orally. Failure to follow after care instructions my compromise the final results of the treatment.
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 Mary's Body Shaping (including is officers, members, owners, employees and agents) from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known of unknown, direct or indirect, asserted or un-asserted, and whether or not on account of myself, Mary's Body Shaping or other third parties, or in any way arising out of the above described treatment I have requested Mary's Body Shaping perform. It is the intention of the parties that this agreement binds all parties whose claim may arise out of or relate to treatment or services provided by Mary's Body Shaping 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 Connecticut law.
I agree to indemnify, hold harmless and defend Mary's Body Shaping (including its officers, members, owners, employees and agents) against all third-party claims, causes of action, damages, judgments, cost or expenses, including attorneys’ fees and other litigation costs, which may in any way arise from the above described treatment I have requested Mary's Body Shaping perform.
By signing and submitting this agreement I confirm that I am over the age of 18, I understand that the Ultrasonic procedure is permanent, that such a 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. This means I fully accept full responsibility for these and/or any other complications which may arise or result during or following the Body Sculpting procedure which is to be performed at my request according to this agreement. I further understand that by signing this agreement, I surrender certain legal rights
Any neurological disorders/diseases?
Please note if you checked any of ABSOLUTE CONTRAINDICATIONS you cannot and will
NOT be treated. NO EXCEPTIONS!
All images may be exhibited in electronic and advertising or printed media at the
discretion of Mary's, Body Shaping always respecting the integrity of the clients.
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