FEES: ALL COSTS ARE TO BE PAID IN FULL PRIOR TO INITIAL TREATMENT AND ARE NON-REFUNDABLE. COSTS

DO NOT INCLUDE FUTURE VISITS, UNLESS OTHERWISE EXPRESSED. CLIENT MUST PAY FOR ANY SPECIAL

OFFERS ON SECOND VISIT TO RECEIVE PACKAGE DISCOUNT. DISCOUNTED PACKAGES ARE NON-REFUNDABLE.

MASSAGE DISCLOSURE: THE MASSAGE IS A PROCESS, AND SUBSEQUENT VISITS MAY BE NECESSARY IN ORDER

TO ACHIEVE THE DESIRED RESULTS. ACTUAL RESULTS VARY FROM PERSON TO PERSON. IULIIA DIUMEA DOES

NOT GUARANTEE ANY SPECIFIC RESULT.

AFTERCARE: PATIENTS ARE REQUIRED TO DRINK AT LEAST 2 LITERS OF WATER ON A DAILY BASIS WHEN

I agree to have photographs taken for documentation, as well as internal use.__________________________

The pictures may be used for its legitimate recordkeeping and social media purposes. I will conceal identities

unless requested otherwise.

Please check this line if you DO NOT give social media consent._____________________________________

RELEASE: I RECOGNIZE THAT THERE ARE CERTAIN INHERENT RISKS ASSOCIATED WITH DEEP TISSUE MASSAGE

ABOVE, AND I ASSUME FULL RESPONSIBILITY FOR THE PERSONAL INJURY TO MYSELF. IN EXCHANGE FOR

DEEP TISSUE MASSAGES, I HEREBY FULLY RELEASE AND FULLY DISCHARGE IULIIA DIUMEA 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 IULIIA DIUMEA OR OTHER THIRD PARTIES

CLAIMS, CAUSES OF ACTION, DAMAGES,JUDGEMENTS,COSTS OR EXPENSES,INCLUDING ATTORNEY’S FEES AND

ANY OTHER LIGITATION COSTS, WHICH MAY IN ANY WAY ARISE FROM THE ABOVE DESCRIBED TREATMENT I

GAVE REQUESTED IULIIA DIUMEA TO PERFORM.

ARBITRATION : IT IS UNDERSTOOD THAT ANY DISPUTE ARISING AS TO MALPRACTICE OF MASSAGE

TREATMENT SGALL BE DECIDED BY A NEUTRAL ARBITRATOR. ANY ARBITRATION WILL BE GOVERNED BY

CALIFORNIA ARBITRATION STATUTES.THE FEES FOR THE ARBITRATOR WILL BE SPLIT PRO-RATA AMONG THE

PARTIES AND EACH PARTY WILL BE RESPONSIBLE FOR THEIR OWN ATTORNEY’S FEES AND COSTS. ANY ACTION

TO COLLECT FEES FROM THE CLIENT/PATIENT FOR THE TREATMENTS PERFORMED MAY BE BROUGHT IN ANY

COURT LOCATED IN CALIFORNIA AND PREVAILING PART.IN SUCH COLLECTION, ACTIONS SHALL BE ENTITLED

TO RECOVER ANY REASONABLE ATTORNEY’S FEES AND COSTS. FILING OF ANY ACTION IN ANY COURT TO

COLLECT ANY FEE FROM CLIENT/PATIENT SHALL NOR WAIVE THE RIGHT TO COMPLETE ARBITRATION OF ANY

MALPRACTICE CLAIM.

RESULTS: I AGREE THAT RESULTS ARE SUBJECTIVE AND THAT MY LIFESTYLE CAN MITIGATE THESE RESULTS.

BY SIGNING THIS AGREEMENT, I CONFIRM THAT I AM OVER THE AGE OF 18. I UNDERSTAND THAT THE

MASSAGE IS PERMANENT, THAT SUCH MASSAGE HAS POSSIBLE ADVERSE CONSEQUENCES, AND THAT THE

MASSAGE IS FOR COSMETIC PURPOSES ONLY.

I CERTIFY THAT I HAVE READ THE ABOVE PARAGRAPHS, FULLY UNDERSTAND THE PROCEDURE’S RISKS AND

HEREBY CONSENT TO THE MASSAGES. THIS MEANS THAT I ACCEPT FULL RESPONSIBILITY FOR THESE AND/OR

 

INTAKE CONSENT FORM

NAME: __________________________________ AGE:____DATE:____________

ADDRESS: ______________

PHONE: ________________ ______________

EMAIL: ____________ _ _______________

Areas of Desired Improvement: Face/Neck______________________________________________

Specific Appearance_________________________________________________________________________

Do any of the following medical conditions apply to you? (Check all that apply)

Pregnancy___

Psoriasis___

Neoplasms(abnormal Nevi)___

Abnormal high or low blood pressure___

herpes virus___

Neuritis of the Facial nerve___

Alopecia___

Enlargedthyroid glands___

oral diseases___

Claustrophobia__

Depression___

Rosacea___

eyes___

PLEASE LIST ANY MEDICATIONS: __________________________________

ARE YOUALLERGIC TO ANY FOODS OR MEDICATIONS? ______________

Do you wear contact lenses?___

Describe your skin type: Normal___ Oily___ Combination___ Dry___

Have you had any recent injection? Biorevitalization ___

Neurotoxin( Botox,Dysport, Juvederm)___

Fillers, based on hyaluronicacid___ Thread lifting___

Long- term implants___

What is the date of your last injection?___

RISKS: JUST AS THERE THERE MAY BE BENEFITS TO THE 0ROCEDURE PROPOSED, I UNDERSTAND THAT

ALL PROCEDURES INVOLVE RISKS TO SOME DEGREE.