Privacy Notice, Informed Consent

and

Waiver of Liability

I acknowledge that the services I am requesting are not medically necessary and are voluntary procedures. I understand that every procedure involves a certain amount of risk. I acknowledge that I have received a list of risks associated with the services and I have disclosed any health-related conditions that may affect the outcome of my service to my technician. I acknowledge that I have received and read the Privacy Notice, Informed Consent, and Waiver of Liability. I have had the opportunity to discuss my questions and/or concerns with my technician, and I understand the possible complications I may experience as a result of the treatment I am requesting.

All procedures whether voluntary or involuntary come with risks, please review the treatment specific warnings below and follow the link to more valuable information regarding your treatments.

Laser Hair Removal - Patient response can vary after a hair reduction treatment. Erythema (redness) and edema (swelling) around the hair follicles in the treated area are sometimes noted within a few minutes after the completion of the procedure and typically completely resolve within 24-48 hours. A sunburn sensation in the area treated is also normal and expected.

For more information concerning risks and basic treatment instruction, please click: Risks of Laser Hair Removal.

SkinTyte® - Patient response can vary after a SkinTyte® treatment.  Erythema (redness) is usually noted within a few minutes after the completion of the procedure. A slight sunburn sensation in and around the area treated is also normal and expected. These reactions tend to subside within 1-4 hours after the treatment. There is a possibility of rare side effects such as scarring and permanent discoloration as well as short term effects such as reddening, mild burning, temporary bruising and temporary discoloration of the skin.  These effects have all been fully explained to me.

For more information concerning risks and basic treatment instruction, please click: Risks of SkinTyte.

Phototherapy - Some skin defect consequences may arise from intrinsic hormonal factors that create an over production of melanin as in melasma or hereditary factors that produce more vessels. Phototherapy involves the reduction of these signs of aging and skin defects using non-invasive pulses of BroadBand Light (BBL).  There is no recovery time and a low risk of complications with Phototherapy treatments.  Multiple sessions are performed every 2-4 weeks until the desired result has been achieved.

For more information concerning risks and basic treatment instruction, please click: Risks of Phototherapy.

Botox® - Botox® injections are relatively safe when performed by an experienced doctor. Possible side effects and complications include: Pain, swelling or bruising at the injection site, Headache or flu-like symptoms, Droopy eyelid or cockeyed eyebrows, Crooked smile or drooling, or Eye dryness or excessive tearing.

For more information concerning risks and basic treatment instruction, please click: Risks of Botox.

DiamondGlow® - Typical side effects include a scratchy, stinging sensation during the treatment and temporary tightness, redness or slight swelling after the treatment. Rare serious side effects may also occur and include severe skin irritation and allergic reactions.

For more information concerning risks and basic treatment instruction, please click: Risks of DiamondGlow.

Hylenex® - Adverse reactions are rare but may include pain or  erythema at the local injection site.

For more information concerning risks and basic treatment instruction, please click:  Risks of Hylenex.

Sciton Moxi® - Clinical results may vary in different skin types and as with any similar type of treatment there is a possibility of rare side effects that may include scarring and permanent discoloration as well as short term effects such as reddening, mild burning, and temporary discoloration of the skin.

For more information concerning risks and basic treatment instruction, please click:  Risks of Sciton Moxi.

Sciton BBL® - Possible side effects may include redness, swelling, itching or hive-like appearance.  

For more information concerning risks and basic treatment instruction, please click:  Risks of Sciton BBL.

B-12 Injections – Pain/redness at the injection site, mild diarrhea, itching, or a feeling of swelling all over the body may occur. If any of these effects persist or worsen consult your physician.

For more information concerning risks and basic treatment instruction, please click: Risks of B-12 Injections.

Chemical Peels – Clinical results vary but some side effects may include redness, swelling or scarring, changes in skin color or infection.

For more information concerning risks and basic treatment instruction, please click:  Risks of Chemical Peels.

LED Light Therapy – Side effects may include increased inflammation, redness, pain or tenderness.

For more information concerning risks and basic treatment instruction, please click: Risks of LED Light Therapy.

Platelet-rich plasma (PRP) Injections – PRP injections are made up of your own cells and plasma, the risk of an allergic reaction is much lower than with other injectable medications.  Less common risks of PRP injections include bleeding, tissue damage or infection.

For more information concerning risks and basic treatment instruction, please click: Risks of PRP Injections.

Facial and Body Waxing - Possible side effects may include inflamed hair follicles, pain, redness, ingrown hairs and skin irritation. Removing female facial hair while using retinoid anti-aging or acne products can lead to abrasions, infection and even scarring.

For more information concerning risks and basic treatment instruction, please click:  Risks of Waxing.

Polydioxanone Thread Lift (PDO)® Complications resulting from PDO treatments are rare but may include inflammation, snapping of threads, hair loss, irritation, stiffness and minor bruising.

For more information concerning risks and basic treatment instruction, please click:  Risks of PDO.

Injectables and Dermal Fillers - The most common side effects include: bruising, redness, swelling, pain, and itching. Additional side effects less commonly reported include: infections, lumps and bumps, and discoloration or change in pigmentation. Rare but serious risks include: scarring, blurred vision, partial vision loss, and blindness if the dermal filler is inadvertently injected into a blood vessel, or allergic reaction that may lead to a severe reaction (anaphylactic shock) that requires emergency medical help.

For more information concerning risks and basic treatment instruction, please click: Risks of Injectables and Dermal Fillers.

Microblading – Complications may include allergic reactions, transmission of infectious diseases, inflammation, bacterial skin infections and other skin problems.

For more information concerning risks and basic treatment instruction, please click: Risks of Microblading.

Emsculpt Neo – Although rare, side effects from this non-invasive treatment may include muscle soreness, redness, swelling, bruising, or numbness.

For more information concerning risks and basic treatment instruction, please click: Risks of Emsculpt Neo.

Body Art/Tattoos – Potential side effects may include allergic reactions, transmission of infectious diseases, inflammation, bacterial skin infections and other skin problems.

For more information concerning risks and basic treatment instruction, please click: Risks of Body Art.

Procedures Generally – Due to the many procedures that Rochester Beauty Bar LLC provides there are other procedures not specifically addressed that may come with a risk of side effects ranging from mild to severe.  If you are unsure about whether you are at risk for any adverse side effects as a result of any procedure offered by Rochester Beauty Bar LLC please consult with your doctor or medical professional prior to undertaking the procedure.

I further understand and acknowledge that some procedures may have unintended consequences that may cause injury to me. I covenant not to sue Rochester Beauty Bar LLC, its agents, associations, employees, technicians, or anyone connected with Rochester Beauty Bar LLC for any claim, damages, costs, or cause of action which I have or may have in the future as a result of injuries or damages sustained or incurred as a result of services I receive from Rochester Beauty Bar LLC as I have been fully informed of any and all risks and hereby assume said risks.

Furthermore, I understand, acknowledge, and agree that Rochester Beauty Bar LLC is not responsible for my personal property. In the unlikely event of a controversy or claim arising out of or relating to this agreement or its breach shall be settled by arbitration administered by the American "Arbitration" Association under its Commercial Arbitration Rules, and judgment on the award rendered by the arbitrator (or arbitrators) may be entered in any court having jurisdiction over it. The substantive law governing any dispute will be the laws of the State of Michigan. I agree that any claim against the Rochester Beauty Bar LLC, whether arising in tort, contract or otherwise, must be brought within Six (6) Months of the date giving rise to the claim or be forever barred.

THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF 1) EQUIPMENT THAT MAY MALFUNCTION OR BREAK; AND 2) AILMENTS DURING OR POST TREATMENT. ALL DAMAGES ARISING OUT OF OR RELATED TO THIS AGREEMENT, WHETHER IN CONTRACT, TORT, OR OTHERWISE, SHALL IN NO EVENT EXCEED FIVE HUNDERED DOLLARS ($500.00). THE PARTIES ACKNOWLEDGE AND ACCEPT THE REASONABLENESS OF THE DISCLAIMERS AND LIMITATIONS OF LIABILITY SET FORTH IN THIS SECTION.

HIPAA COMPLIANCE

THIS NOTICE OF PRIVACY PRACTICES (“NOTICE”) DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION AND HOW YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE READ IT CAREFULLY.

ABOUT THIS NOTICE

This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates, and our Business Associates’ subcontractors, may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO), and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.

“Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services. 

We are required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such information, and to abide by the terms of this Notice. We are also required by law to notify affected individuals following a breach of their unsecured health information. 

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your aesthetician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing aesthetic treatment services to you, to pay your health care bills, to support the operation of the beauty salon, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your care with a third party. For example, your protected health information may be provided to an aesthetician to whom you have been referred to ensure that the aesthetician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your aesthetic treatment services.

Aesthetic Treatment Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your beauty salon. These activities include, but are not limited to, quality assessment, employee review, training of students, licensing, fundraising, and conducting or arranging for other business activities. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other beauty-related benefits and services that may be of interest to you.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request.

Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with legal requirements. 

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization, or opportunity to object, unless required by law. Without your authorization, we are expressly prohibited from using or disclosing your protected health information for marketing purposes. We may not sell your protected health information without your authorization. We may not use or disclose notes contained in your protected health information.

You may revoke the authorization, at any time, in writing, except to the extent that your aesthetician or the beauty salon has taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS

The following are statements of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information (fees may apply)

– Pursuant to your written request, you have the right to inspect or copy your protected health information whether in paper or electronic format. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.

You have the right to request a restriction of your protected health information

This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your aesthetician is not required to agree to your requested restriction except if you request that the aesthetician not disclose protected health information to your health plan with respect to aesthetic treatments for which you have paid in full out of pocket.

You have the right to request to receive confidential communications

You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You have the right to request an amendment to your protected health information

If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures

You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of the request.

You have the right to receive notice of a breach

We will notify you if your unsecured protected health information has been breached.

You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically.

We will also make available copies of our new notice if you wish to obtain one.

We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment.

COMPLAINTS

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

I, the undersigned client, acknowledge that I have read and understood the above Agreement, Privacy Notice Regarding HIPAA, and Waiver of Liability. I further acknowledge that I have read and understood the relative informed consent form for the treatment I have selected.

AGREED:

Print Name:______________________Signature:______________________

Date:_________