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Large Volume Client Form

Precision Hair Removal and Skin Care LLC
3612 Lake Avenue, Wilmette, IL 60091
(773) 654-1132 • info@precisionhairremoval.com

Client Health History
Liability Waiver and Agreement

Treatment Area(s):
Legal Name:		Preferred Name:
Gender: Date of Birth: Phone: Email:
Address:		Emergency Contact Name/Phone/Relationship:
Instructions for calling:
Referred?		If yes, by whom?:

Medications/Implants/Body Mods:

Current Medications:

Medical Conditions:

Other Medical Conditions:

Allergies:

Other Allergies:

Skin Treatments:

Surgeries within last or next 90 days:

Doctor approval?

Temporary hair removal methods:

Had electrolysis?

Hours:

Location of treatment:

Sensitivity and results:

Had laser?

Number of Sessions:

Location of treatment:

Sensitivity and results:

Notes:

Name & Address of Physician:

All past surgeries:

Hair Growth Photos

PAYMENT, CANCELLATION POLICY, AND TREATMENT ACKNOWLEDGEMENTS

• I agree that all treatment pricing information has been explained to me in full and to my satisfaction.
• I agree that a 3.5% fee will be added to any balance paid by credit or debit card.
• I agree that I will pay a deposit to reserve an appointment.
• I agree that I will forfeit my deposit if I cancel or reschedule my treatment with notice of less than 14 calendar days before my appointment.
• I agree to pay my balance in full on or before the date of treatment.
• I agree that the treatment has been explained to me in full and I have had all of my questions answered to my satisfaction.
• I understand that electrology and permanent hair removal is a learning experience that involves many factors for my technician as well as myself.
• I understand health history information is important to the Electrologist and medical providers in order to provide me with safe and effective hair removal treatments and other services. I declare all information given by me is accurate to the best of my knowledge and I agree to update my health history information when there are changes.
• I understand permanent hair removal requires a treatment program that involves a series of treatments based on my previous methods of hair removal, the science of electrology, and my individual physiological factors.
• I understand that I must use a complete skin care regimen, before, during, and after my treatment series to enhance my treatment results.• I understand that PRECISION recommends that I receive professional facial treatments before, during, and after my treatment series to enhance treatment results.• I understand that I may wish to seek, at my sole cost, micro-needling, chemical peels, laser skin resurfacing and/or other skin treatments following my electrolysis treatment series to improve the appearance of my skin.
• I authorize PRECISION HAIR REMOVAL AND SKIN CARE LLC and its Independent Contractors to take and maintain photographs for the purpose of personal records, case history, training, and references.
• I have been advised of the post-treatment healing process, I agree to follow all aftercare instructions and to notify PRECISION HAIR REMOVAL AND SKIN CARE LLC immediately of any concerns or difficulty in healing.
• I understand that the process of electrolysis, as with any type of hair removal, carries inherent risks of scarring or other skin irritations or damage.

WAIVER

IT IS THE PURPOSE OF THIS AGREEMENT FOR THE PATIENT TO EXEMPT, WAIVE AND RELIEVE PRECISION HAIR REMOVAL AND SKIN CARE LLC AND ITS INDEPENDENT CONTRACTORS (“PRECISION”) FROM LIABILITY FOR PERSONAL INJURY, DAMAGES, OR WRONGFUL DEATH, INCLUDING IF CAUSED BY NEGLIGENCE, BY PRECISION HAIR REMOVAL AND SKIN CARE LLC, ITS MANAGERS, EMPLOYEES AND/OR INDEPENDENT CONTRACTORS.

For and in consideration of the undersigned Patient’s registration and treatment with Precision, Patient (and the parent(s) or legal guardian(s) of Patient, if applicable) waives, releases and relinquishes any and all claims for liability and cause(s) of action, including for personal injury or wrongful death occurring to Patient, arising out of procedures and treatment with Precision, whenever or however such may occur and for such period said procedures may continue, and by this Agreement any such claims, rights, and causes of action that Patient (and Patient’s parent(s) or legal guardian(s), if applicable) may have are hereby waived, released and relinquished, and Patient (and parent(s)/ guardian(s), if applicable) does(do) so on behalf of Patient’s heirs, executors, administrators and assigns.

Patient (and Patient’s parent(s)/guardian(s), if applicable) acknowledges, understands and assumes all risks relating to treatment and any Precision procedures, and understands that this treatment involves risks to Patient’s person including bodily injury, partial or total disability, paralysis and death, and damages which may arise therefrom and that the Patient has full knowledge of said risks. These risks and dangers may be caused by the negligence of the Patient or the negligence of others, including Precision, its employees, or Independent Contractors. Patient (and Patient’s parent(s)/guardian(s), if applicable) further acknowledges that there may be risks and dangers not known or not reasonably foreseeable at this time. Patient (and Patient’s parent(s)/ guardian(s), if applicable) acknowledge, understand and agree that all of the risks and dangers described throughout this Agreement, are included within the waiver, release and relinquishment described herein.

If the law in any controlling jurisdiction renders any part of this Agreement unenforceable, the remainder of this Agreement shall nevertheless remain enforceable to the full extent, if any, allowed by controlling law. This Agreement affects your legal rights, and you may wish to consult an attorney concerning this Agreement. Patient (and Patient’s parent(s)/guardian(s), if applicable) acknowledge that they have been provided and have read the above paragraphs and have not relied upon any representations of Precision, that they are fully advised of the potential dangers of such treatment, that they agree to and sign this document voluntarily, understanding that these waivers and releases are necessary to allow Precision to operate.

I, the Patient, hereby release PRECISION HAIR REMOVAL AND SKIN CARE LLC, its managers, employees and/or independent contractors of all responsibility concerning any injury, skin damage, incident, or other damage that may result from my treatment.

THE ZUKOWSKI CENTER FOR COSMETIC SURGERY

* This release authorizes the disclosure of records for one year from the date signed. I understand that these records may be protected under Federal and/or State law and cannot be disclosed without written consent unless otherwise provided by law. I further understand that the specific type information to be disclosed may, if applicable, include: diagnosis, prognosis, and treatment for physical and/or mental illness, including treatment of alcohol or substance abuse, auto-immune deficiency syndrome (AIDS), AIDS related complex (ARC) or human immunodeficiency virus (HIV) infection for any admissions. I understand that I have the right to revoke this consent at any time unless the facility, which is to make the disclosure of information, has already done so in reliance on the consent.

• I hereby authorize PRECISION HAIR REMOVAL AND SKIN CARE LLC and/or its independent contractors to release my Client Medical/Case History/Information and Evaluation Record, to the Zukowski Center for Cosmetic Surgery for the purpose of evaluation, prescription and administration of pain, comfort and anti-swelling medications during hair removal sessions.

• I understand and agree that I will receive all or part of the following comfort protocol:

- Topical Anesthetic
- IV & Sedation
- Local Anesthetic Injections

• I recognize that during the course of the medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I, therefore authorize the above physician to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time the procedure is begun.
• I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications and injury.
• I acknowledge that no guarantee has been given by anyone as to the results that may be obtained. I am aware of the elective nature of this (these) procedure(s).
• I consent to the disposal of any tissue, medical devices or body parts which may be removed.
• It has been explained to me in a way that I understand:
      - The above treatment or procedure(s) to be undertaken
      - There may be alternative procedures or methods of treatment
      - There are risks to the procedures or treatment proposed.
• I consent to the treatment procedure and above-listed items.

Parent or Legal Guardian Release applicable?:

I HEREBY AUTHORIZE PRECISION HAIR REMOVAL AND SKIN CARE LLC, ITS EMPLOYEES AND INDEPENDENT CONTRACTORS; ZUKOWSKI CENTER FOR COSMETIC SURGERY, ITS OWNERS AND INDEPENDENT CONTRACTORS TO PERFORM THE ABOVE DESCRIBED SERVICES FOR . I UNDERSTAND AND AGREE TO THE ABOVE DESCRIBED WAIVERS, POLICIES, AND RELEASES.

PARENT OR LEGAL GUARDIAN NAME:

SIGNATURE OF PATIENT (or PARENT OR LEGAL GUARDIAN (if applicable)):

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July 27, 2023 9:46 pm CDT

Large Volume Client Form Uploaded by Irina Cardos - info@precisionhairremoval.com IP 73.51.43.10