General Waiver/Consultation Waiver/Consultation Patient Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) How Did You Hear About Us?Areas of Desired Improvement(Required)Medical History Pregnancy Epilepsy Cardiac or Vascular Disease/Condition Acute Inflammation Unhealed Wounds History of Internal Bleeding Pacemaker or Other Electronic Devices Plastic, Bone Cement or Metal Implants Recent Abdominal Surgery Abnormal High or Low Blood Pressure Lose Breath Easily High Cholesterol Communicable Diseases Melanoma Thrombosis or Thrombophlebitis Transplant Taking any Anti-Coagulants Keloids Heart Trouble Current Infection Any Infections, Diseases or Tuberculosis Diabetes Kidney or Liver Disease Migraines Menstruation Check all that ApplyPlease List Any Medications TREATMENT DISCLOSURE: THE TREATMENT IS A PROCESS AND SUBSEQUENT VISITS MAY BE NECESSARY IN ORDER TO ACHIEVE THE DESIRED RESULTS. ACTUAL RESULTS VARY FROM PERSON TO PERSON. ANEW, LLC., DAB ANEW, BODY, BEAUTY AND WELLNESS SPA DOES NOT GUARANTEE ANY SPECIFIC RESULT. AFTERCARE: PATIENTS ARE RECOMMENDED TO DRINK AT MINIMUM 1.5 LITERS OF WATER ON A DAILY BASIS WHEN UNDERGOING THIS TREATMENT. IT IS ENCOURAGED TO COMPLETE A 30-45 MIN CARDIO WORKOUT AFTER THIS TREATMENT. AFTERCARE INSTRUCTIONS HAVE TO BE FOLLOWED EXACTLY WHETHER GIVEN IN WRITING OR VERBALLY. FAILURE TO FOLLOW AFTERCARE INSTRUCTIONS MAY COMPROMISE THE FINAL RESULTS OF THE TREATMENT. BEFORE, DURING AND AFTER PHOTO: BEFORE, DURING OR AFTER PICTURES MAY BE TAKEN TO DOCUMENT YOUR TREATMENT. THESE PICTURES BECOME ANEW, LLC., DBA ANEW, BODY, BEAUTY AND WELLNESS SPA’S SOLE PROPERTY AND ARE ONLY USED FOR LEGITIMATE RECORD KEEPING. 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 FULLY DISCHARGE ANEW, LLC., DBA ANEW, BODY, BEAUTY AND WELLNESS SPA, FROM ANY AND ALL DAMAGES, COSTS, EXPENSES, LIABILITIES, CAUSE OF ACTION, CLAIMS AND DEMANDS OF WHATEVER CHARACTER IN LAW OR EQUITY, WHETHER KNOWN OR UNKNOWN, DIRECT OR INDIRECT, ASSERTED OR UNASSERTED AND WHETHER OR NOT IN ACCOUNT OF MYSELF OR ANEW LLC., DBA ANEW, BODY BEAUTY AND WELLNESS SPA., OR OTHER THIRD PARTIES WHOSE CLAIMS MAY ARISE OUT OF OR RELATED TO THE TREATMENT PROVIDED BY ANEW, LLC., DBA ANEW, BODY, BEAUTY AND WELLNESS SPA. ANY LEGAL OR EQUITABLE CLAIM THAT MAY ARISE FROM PARTICIPATION SHALL BE RESOLVED UNDER THE STATE OF CALIFORNIA LAW. RESULTS: I AGREE THAT RESULTS ARE SUBJECTIVE AND THAT MY LIFESTYLE CAN MITIGATE THESE RESULTS; THEREFORE, THE COST OF THE PROCEDURES ARE NON-REFUNDABLE. BY SIGNING THIS AGREEMENT, I CONFIRM THAT I AM OVER THE AGE OF 19. I UNDERSTAND THAT THE PROCEDURE IS PERMANENT, THAT SUCH 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 THE PROCEDURES RISKS AND HEREBY CONSENT TO THE INDICATED PROCEDURES. THIS MEANS I ACCEPT FULL RESPONSIBILITY FOR THESE AND/OR ANY OTHER COMPLICATIONS WHICH MAY ARISE OR RESULT DURING OR FOLLOWING THE PROCEDURE, WHICH IS TO BE PERFORMED AT MY REQUEST. I FURTHER UNDERSTAND THAT THE COST OF THESE PROCEDURES ARE NON-REFUNDABLE AND THAT BY SIGNING THIS AGREEMENT, I VOLUNTARY SURRENDER CERTAIN LEGAL RIGHTS.Patient Signature(Required)Date(Required) MM slash DD slash YYYY ANEW, LLC. DBA ANEW, BODY, BEAUTY AND WELLNESS SPA, AND OUR STAFF PRIDE OURSELVES ON ENSURING THAT ALL OF OUR PATIENTS ARE SEEN ON TIME, WITHOUT ANY UNNECESSARY WAIT TIMES TYPICALLY EXPERIENCED WITH OTHER SERVICE FACILITIES. TO ACCOMPLISH THIS, WE RELY UPON OUR PATIENTS COMMITMENT TO KEEPING APPOINTMENTS THEY HAVE SCHEDULED FOR THEIR CONVENIENCE. THEREFORE, PLEASE NOTIFY US 24 HOURS IN ADVANCE IF YOU CANNOT KEEP YOUR APPOINTMENT SO WE HAVE THE OPPORTUNITY TO SCHEDULE ANOTHER PATIENT WITHIN YOUR APPOINTMENT TIME. ANY APPOINTMENTS MISSED OR CANCELLED THE DAY OF THE PROCEDURE WILL AUTOMATICALLY ASSESS A $50.00 FEE TO PARTIALLY COVER THE COST OF THE TECHNICIAN ASSIGNED TO YOUR APPOINTMENT. AN INVOICE WILL BE SENT TO YOUR EMAIL WITH THE PENALTY FEE. PLEASE BE ADVISED YOU CANNOT BOOK OR BE SEEN UNTIL THE $50.00 FEE IS PAID IN FULL.Patient Signature(Required)Date MM slash DD slash YYYY Daljeet Arora2022-09-28T18:16:03+00:00