Informed Consent for Non-Surgical Body Contouring / Skin Therapies:
• I understand that specific procedure(s) elected are relatively new industries and long-term safety or effectiveness has not been scientifically validated at this time. I understand that each person has a different response to Body Contouring.
• I understand that the procedure(s) do not correct health problems, including but not limited to diabetes, heart attack, stroke, high cholesterol, blood clots, lung problems, stomach, intestinal problems, bladder disease, an abnormality of the skin, etc. Chelly Jae Fit, LLC is NOT a medical practice and does not make medical decisions. You must consult with your primary care physician for medical advice.
• I understand that I may need post-procedure care. I will dutifully be responsible and compliant with the recommendations from my clinician at Chelly Jae Fit, LLC., which may include, but are not limited to skin care products, diet / exercise, water intake, supportive garments, follow-up procedures, etc.
• I understand that procedures involve risk. Risk may include, but not limited to redness, swelling, irritation, burns, skin reactions, etc. I must immediately report any unusual symptoms known to me to my clinician at Chelly Jae Fit, LLC that includes, but is not limited to being aware of any slight nature or prominence of persistent chills, fever, redness, increased warmth, excessive bruising or swelling, etc. at the sights treated and systematically.
• I give Chelly Jae Fit, LLC permission to use data about my treatment for research purposes. I understand that my name and personal identifying information will remain confidential unless I have written permission to disclose this information. I give Chelly Jae Fit, LLC permission to photograph / record my procedure(s) in a professional manner.
• I have decided that the benefits of body contouring outweigh the potential for complications and all claims have not been evaluated by any regulatory board. I understand the nature of the procedure(s) and / all possible risks mentioned and not limited to. I attest that I am of clear mind, competent, and not under any distress.
Alternative Treatments:
• It has been explained that other temporary and more permanent treatments are available to sculpt, contour, tone, exfoliate, clean, and detoxify the body. Alternative forms of management include receiving no treatment at all. If treatment is chosen alternative body sculpting therapies and other services offered include those offered at Chelly Jae Fit, LLC. Surgical options include Liposuction, Tummy Tucks, Fat Transfer, Muscle Repair etc. I understand that risk and potential complications are associated with these and alternative forms of non-surgical and surgical treatments.
Release of Liability:
• I certify that I am not pregnant or nursing.
• I understand that no guarantees or warranties have been made to me regarding the outcome or any improvements to my condition due to the procedure(s) I have elected to undergo. I am paying for a service and not desired results from treatments. I have been given the opportunity to ask questions and have received satisfactory answers to those questions by the treating staff representative.
• I consent to the taking of photographs/video for documentation during my treatment(s) unless otherwise stated to Chelly Jae Fit, LLC. These photos may be used for marketing and/or publication for the further benefit of educating the public. All attempts will be made to protect my identity.
• I agree to indemnify, hold harmless and release Chelly Jae Fit, LLC, its employees, members, representatives, affiliated organizations, and others acting on the Company's behalf of all claims, demands, causes of action, and legal liability, whether the same be known or unknown, anticipated or unanticipated. I further agree that no claims, demands, legal actions, and causes of action shall be made against Chelly Jae Aesthetics for any economic and non-economic losses of any kind.
• I certify that I have read and fully understand the contents of this form and that the disclosures referred to the above were made prior to my signing the form below. I agree to the terms listed above.
• I acknowledge that I have had the fair opportunity to ask questions and consult with Chelly Jae Fit, LLC. I acknowledge that my questions have been answered to my satisfaction. I understand and accept the potential risks and / or complications involved. I understand that this transaction is final and I will not receive any reinstatement of compensation or refund following services.
• I understand that specific procedure(s) elected are relatively new industries and long-term safety or effectiveness has not been scientifically validated at this time. I understand that each person has a different response to Body Contouring.
• I understand that the procedure(s) do not correct health problems, including but not limited to diabetes, heart attack, stroke, high cholesterol, blood clots, lung problems, stomach, intestinal problems, bladder disease, an abnormality of the skin, etc. Chelly Jae Fit, LLC is NOT a medical practice and does not make medical decisions. You must consult with your primary care physician for medical advice.
• I understand that I may need post-procedure care. I will dutifully be responsible and compliant with the recommendations from my clinician at Chelly Jae Fit, LLC., which may include, but are not limited to skin care products, diet / exercise, water intake, supportive garments, follow-up procedures, etc.
• I understand that procedures involve risk. Risk may include, but not limited to redness, swelling, irritation, burns, skin reactions, etc. I must immediately report any unusual symptoms known to me to my clinician at Chelly Jae Fit, LLC that includes, but is not limited to being aware of any slight nature or prominence of persistent chills, fever, redness, increased warmth, excessive bruising or swelling, etc. at the sights treated and systematically.
• I give Chelly Jae Fit, LLC permission to use data about my treatment for research purposes. I understand that my name and personal identifying information will remain confidential unless I have written permission to disclose this information. I give Chelly Jae Fit, LLC permission to photograph / record my procedure(s) in a professional manner.
• I have decided that the benefits of body contouring outweigh the potential for complications and all claims have not been evaluated by any regulatory board. I understand the nature of the procedure(s) and / all possible risks mentioned and not limited to. I attest that I am of clear mind, competent, and not under any distress.
Alternative Treatments:
• It has been explained that other temporary and more permanent treatments are available to sculpt, contour, tone, exfoliate, clean, and detoxify the body. Alternative forms of management include receiving no treatment at all. If treatment is chosen alternative body sculpting therapies and other services offered include those offered at Chelly Jae Fit, LLC. Surgical options include Liposuction, Tummy Tucks, Fat Transfer, Muscle Repair etc. I understand that risk and potential complications are associated with these and alternative forms of non-surgical and surgical treatments.
Release of Liability:
• I certify that I am not pregnant or nursing.
• I understand that no guarantees or warranties have been made to me regarding the outcome or any improvements to my condition due to the procedure(s) I have elected to undergo. I am paying for a service and not desired results from treatments. I have been given the opportunity to ask questions and have received satisfactory answers to those questions by the treating staff representative.
• I consent to the taking of photographs/video for documentation during my treatment(s) unless otherwise stated to Chelly Jae Fit, LLC. These photos may be used for marketing and/or publication for the further benefit of educating the public. All attempts will be made to protect my identity.
• I agree to indemnify, hold harmless and release Chelly Jae Fit, LLC, its employees, members, representatives, affiliated organizations, and others acting on the Company's behalf of all claims, demands, causes of action, and legal liability, whether the same be known or unknown, anticipated or unanticipated. I further agree that no claims, demands, legal actions, and causes of action shall be made against Chelly Jae Aesthetics for any economic and non-economic losses of any kind.
• I certify that I have read and fully understand the contents of this form and that the disclosures referred to the above were made prior to my signing the form below. I agree to the terms listed above.
• I acknowledge that I have had the fair opportunity to ask questions and consult with Chelly Jae Fit, LLC. I acknowledge that my questions have been answered to my satisfaction. I understand and accept the potential risks and / or complications involved. I understand that this transaction is final and I will not receive any reinstatement of compensation or refund following services.