CLIENT INFORMATION & MEDICAL HISTORY
Welcome to Nyah Med Spa! We are looking forward to your first visit. Every new client must book a free initial consultation prior to treatment. This will allow us to assess your skin/hair type and perform a test spot with the laser to make sure you do not have any adverse reaction. You will be able to start your treatments 48 hours after the test spot.
In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.
PERSONAL HISTORY
Which of the following best describes your skin type?
I - Always burns, never tans
II - Always burns, sometimes tans
III - Sometimes burns, always tans
IV - Rarely burns, always tans
V - Brown, moderately pigmented skin
VI - Black skin
TREATMENT HISTORY
Have you ever had laser hair removal?*
Yes No
Have you used any of the following hair removal methods in the past six weeks?
Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories
Have you had any recent tanning or sun exposure that changed the color of your skin?*
Yes No
Have you recently used any self-tanning lotions or treatments?*
Yes No
Do you form thick or raised scars from cuts or burns?*
Yes No
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
Yes No
For our female clients:
Are you pregnant or trying to become pregnant?*
Yes No
Are you breastfeeding?*
Yes No
Are you using contraception?*
Yes No
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
Date:
Signature:
MEDICAL HISTORY
Are you currently under the care of a physician?*
Yes No
Are you currently under the care of a dermatologist?*
Yes No
Do you have any of the following medical conditions? (Please check all that apply)
Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?*
Yes No
Do you have any other health problems or medical conditions? Please list:
Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you experienced)
Client Treatment Consent and Release
I acknowledge that beauty treatments, the practice of skin care, and the practice of massage, including, but not limited to, microablation, microdermabrasion, waxing, electrolysis, facial toning, permanent cosmetics, body treatments, ionization, laser treatments, tattoo removal, vin treatments, brown spot removal, BOTOX, Collagen, Dermal Fillers, Sclerotherapy, Mesotherapy, Dermaplaning, and various other beauty procedures is not an exact science and no specific guarantees can or have been made concerning the outcome. I understand that some clients 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 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, change in skin pigmentation, allergic reaction, muscle damage, and increased hair growth. I understand that even tough 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 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.
Date:
Signature:
SPA POLICIES
We respect your time and appreciate your choice to spend it with NYAH Med Spa. We've created our Spa Policies to provide the utmost versatility and convenience to our guests. Booking a reservation is your acceptance of our Spa Policies; therefore, please be certain you've reviewed and agreed to these terms.
Please respect our scheduling by keeping appointments whenever possible and providing a minimum of 24 hour notice when canceling or rescheduling appointments. Failure to comply with these guidelines will result in a loss of treatment or a fee of $25.
- Less than 24-hour notification to cancel or reschedule an appointment.
- No-show or missed appointments.
- Late arrivals - please keep in mind that arriving late for a service may require us to shorten the length of the treatment, with full charges applied, so as not to inconvenience other guests. We regret that late arrivals will not receive extension of scheduled appointments unless our schedule allows.
- We have a NO REFUND policy, however we will consider an exchange for other services.
- Vouchers are accepted from NEW CLIENTS ONLY; Vouchers from existing Clients will not be redeemed. We consistently offer extremely competitive in-house prices on our services and for this reason we can NOT extend any voucher exceptions to our existing clients.
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NAD+ Injection Consent Form
Administered by: RN Angela Smith
Patient Information
Full Name:
Date of Birth:
Phone Number:
What is NAD+?
NAD+ (Nicotinamide Adenine Dinucleotide) is a coenzyme found in every cell of the body and is essential for energy production, DNA repair, and healthy aging. NAD+ injections are designed to help improve mental clarity, boost energy levels, support cellular function, and promote overall wellness.
Potential Benefits of NAD+ Injections
Increased energy and stamina
Improved focus and mental clarity
Enhanced mood and cognitive performance
Reduced inflammation and improved detoxification
Anti-aging and cellular repair support
Possible Side Effects
Common Side Effects:
• Nausea or stomach discomfort: This is one of the most common side effects, especially with higher doses or faster infusion rates. It typically subsides as the body adjusts.
• Fatigue: Some individuals may feel tired or fatigued after the session as their body adjusts.
• Headaches: Mild headaches are also reported by some patients during or after treatment, usually temporary.
• Flushing or warmth: A sensation of warmth or flushing of the face or body can occur, typically transient.
• Injection site reactions: Pain, redness, swelling, or bruising at the injection site are possible, but usually temporary.
• Brain fog: A small subset of patients may experience temporary brain fog or feeling mentally cloudy.
• Muscle pain or cramping: Some individuals may notice muscle discomfort or cramping.
• Diarrhea: This can occur, though it is less common.
Rare Side Effects:
• Allergic Reactions: While rare, allergic reactions to components of the NAD IV solution, such as preservatives or additives, can occur.
• Infections: Risk of infection exists with any IV therapy, especially if proper sterilization protocols are not followed.
• Vein Inflammation (Phlebitis): This can happen with poorly administered IV therapy.
• Decreased Insulin Sensitivity: Some research suggests that high doses of NAD might decrease insulin sensitivity, a concern for individuals with prediabetes or diabetes.
• Potential Liver Strain: Studies on this are ongoing, but it's a possibility with high doses.
Flushing or warmth during the injection
Nausea or upset stomach
Dizziness or lightheadedness
Muscle soreness at the injection site
Headache or fatigue
Notify your provider immediately if you experience shortness of breath, chest pain, or any other concerning symptoms.
Contraindications
You should not receive NAD+ injections if you:
Are pregnant or breastfeeding
Have an allergy to nicotinamide or NAD+ components
Are currently undergoing chemotherapy or radiation
Have certain metabolic or mitochondrial disorders (consult your physician)
Consent & Acknowledgment
I understand the purpose, benefits, and possible risks of NAD+ injections.
I have informed the staff of any known allergies, medical conditions, or medications I am currently taking.
I understand that results may vary from person to person and that no specific outcome is guaranteed.
I give permission to RN Angela, to administer NAD+ injections at Nyah Med Spa.
I understand that this is a wellness treatment and is not a substitute for professional medical care.
I have had the opportunity to ask questions and they have been answered to my satisfaction.
Authorization
By signing below, I confirm that I have read and fully understand this consent form. I understand the potential benefits and risks and voluntarily agree to receive NAD+ injection therapy.
Patient Signature:
Date:
Liability Waiver
By signing this form, I acknowledge and agree that I will not hold Nyah Med Spa or RN Angela Smith liable for any injury, side effect, or adverse outcome resulting from the administration of NAD+ injections. I voluntarily release, discharge, and waive any and all claims, demands, or actions against Nyah Med Spa and RN Angela Smith. This includes, but is not limited to, any claims of negligence, malpractice, or liability for any damages or losses incurred. I understand that by signing this agreement, I am waiving my right to pursue legal action, including taking Nyah Med Spa or RN Angela Smith to court, regarding any aspect of my NAD+ injection therapy.
Self-Administration Acknowledgment
I acknowledge that I have received thorough instructions and explanations from RN Angela Smith regarding the proper technique, dosage, and safety procedures for administering subcutaneous NAD+ injections at home. I understand how to properly administer these injections and have had the opportunity to ask questions, all of which have been answered to my satisfaction. I feel confident in my ability to safely self-administer the injections and take full responsibility for doing so. I acknowledge that any complications or adverse reactions resulting from self-administration are my responsibility, and I release Nyah Med Spa and RN Angela Smith from any liability related to my self-administration of NAD+ injections.
I have read and understand all the above statements. I voluntarily agree to proceed with NAD+ injection therapy, including self-administration at home, and acknowledge all associated risks and responsibilities.
Client Name (Printed):
Client Signature:
Date:
WAIVER AND RELEASE OF LIABILITY
IN CONSIDERATION OF the risk of injury that exists while participating in MEDICAL SPA (hereinafter the "Activity"); and
IN CONSIDERATION OF my desire to participate in said Activity and being given the right to participate in same;
I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, "Releasor," "I" or "me", which terms shall also include Releasor's parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity; and
I HEREBY release and forever discharge NYAH MED SPA, located at 5755 N Point Pkwy Ste 55, Alpharetta, Georgia 30022, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively "Releasees"), from any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned Activity.
I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO: PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, DISFIGUREMENT, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS), ECONOMIC OR EMOTIONAL LOSS, AND DEATH. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS' NEGLIGENCE, CONDITIONS RELATED TO TRAVEL TO AND FROM THE ACTIVITY, OR FROM CONDITIONS AT THE ACTIVITY LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY.
I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs.
I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize Nyah Med Spa to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.
I FURTHER ACKNOWLEDGE that this Activity may involve a test of a person's physical and mental limits and may carry with it the potential for death, serious injury, and property loss. I agree not to participate in the Activity unless I am medically able and properly trained, and I agree to abide by the decision of the Nyah Med Spa official or agent, regarding my approval to participate in the Activity.
I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE Nyah Med SpaAND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST Nyah Med Spa FOR PERSONAL INJURY OR PROPERTY DAMAGE.
To the extent that statute or case law does not prohibit releases for ordinary negligence, this release is also for such negligence on the part of Nyah Med Spa, its agents, and employees.
I agree that this Release shall be governed for all purposes by Georgia law, without regard to any conflict of law principles. This Release supersedes any and all previous oral or written promises or other agreements.
In the event that any damage to equipment or facilities occurs as a result of my or my family's or my agent's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any such actions of neglect or recklessness.
THIS WAIVER AND RELEASE OF LIABILITY SHALL REMAIN IN EFFECT FOR THE DURATION OF MY PARTICIPATION IN THE ACTIVITY, DURING THIS INITIAL AND ALL SUBSEQUENT EVENTS OF PARTICIPATION.
THIS AGREEMENT was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both Participant, and Nyah Med Spa agree that this agreement is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted to alter or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.
In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.
In the event of an emergency, please contact the following person(s) in the order presented:
I, THE UNDERSIGNED PARTICIPANT, AFFIRM THAT I AM OF THE AGE OF 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. I CERTIFY THAT I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND ITS CONTENT AND THAT THIS RELEASE CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.
Signature
Date
Participant's Name:
Participant's Address: