Client Treatment Consent, Waiver & Release
I acknowledge that bioelectric stimulation treatments and related biologics procedures, if any, are not an exact science and no specific guarantees can or have been made concerning the outcome related to both safety and efficacy.
I understand that some clients may 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 fully and undeniably 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, and 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 understand clearly and fully that the stimulation device being used in these procedures only has FDA 510K market clearance for these indications of use:
1. Improving blood circulation.
2. Mild pain relief.
3. Improving muscle motion.
I further understand that the above may not improve my condition being treated. I understand the company, its employees, its advisors, board directors, suppliers and clinical collaborators in no way make any claim(s) that the device or methods have been proven safe or efficacious for the purposes of treating my condition. Improving blood circulation, relieving pain and improving muscle motion may possibly help with my condition but may not.
I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect 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.
Model, Photographs and Data Use Release
In consideration for treatment received, I hereby 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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Document Name: Client Treatment Consent, Waiver & Release
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