Please enable JavaScript in your browser to complete this form.
Name
Address
Email
Are you experiencing any of the following symptoms ? (Select all that apply)
Are you Currently using anything for hair loss? check all that apply
Have you seen a dermatologist or other doctor for your hair loss?
CONTRAINDICATIONS/ MEDICAL DIAGNOSIS
Have you had Bariatric Surgery of any sort?
Have you lost significant amounts of weight in a short period of time?
Ave you or are u currently taking any of these Medications?
What kind of hair loss are you experiencing?
Have you ever had an allergic reaction to any of the following?
Are you over the age of 18?
Click or drag a file to this area to upload.
COMPREHENSIVE LIABILITY WAIVER AND RELEASE AGREEMENT This Comprehensive Liability Waiver and Release Agreement (“Agreement”) is made by and between Chana’s Beauty LLC, Chana Horowitz, and any authorized representatives, employees, agents, affiliates, successors, and assigns (collectively, “Chana’s Beauty”) and the undersigned client (“Client”). 1. VOLUNTARY PROCEDURE & NO GUARANTEES The Client acknowledges and agrees that they are undergoing this procedure of their own free will and have not been coerced, misled, or unduly influenced into receiving this treatment. The Client understands and agrees that: • This procedure is being performed for cosmetic purposes only and is purely elective. • No guarantees, warranties, or assurances have been made concerning the results, effectiveness, longevity, or satisfaction of the procedure. • Multiple treatments may be required to achieve optimal results, and results may vary between individuals. 2. POTENTIAL RISKS & COMPLICATIONS The Client acknowledges that while every precaution will be taken to ensure their safety, there are inherent risks associated with this procedure, which may include, but are not limited to: • Infection, swelling, redness, irritation, scarring, or discomfort. • Allergic reactions to products, anesthetics, or topical solutions used during or after the procedure. • Unintended or unsatisfactory results, including but not limited to uneven pigmentation, fading, color change, or undesired appearance. • Prolonged or unexpected healing time, sensitivity, or adverse reactions due to individual skin type, pre-existing conditions, or external factors. The Client fully understands and accepts all risks involved and acknowledges that complications, although rare, can and sometimes do occur. 3. RELEASE OF LIABILITY & INDEMNIFICATION The Client, on behalf of themselves, their heirs, assigns, executors, administrators, and legal representatives, expressly waives, releases, discharges, and forever holds harmless Chana’s Beauty LLC, Chana Horowitz, and any affiliated persons or entities from any and all claims, demands, liabilities, judgments, costs, expenses, or damages—whether direct, indirect, incidental, consequential, foreseeable, or unforeseeable—arising out of or in connection with: • The procedure, including any side effects, reactions, or complications. • The results of the procedure, including any dissatisfaction with aesthetic outcomes. • Any allergic reaction or sensitivity to products or materials used. • Any financial losses, including the non-refundable nature of deposits and payments. Furthermore, the Client agrees to fully indemnify, defend, and hold harmless Chana’s Beauty and Chana Horowitz from any and all claims, lawsuits, or legal actions, including but not limited to attorney fees, court costs, and damages, arising out of or related to the procedure. 4. NON-REFUNDABLE POLICY The Client fully understands and agrees that any and all deposits, consultation fees, and procedural payments are strictly non-refundable, regardless of circumstances, including but not limited to: • Dissatisfaction with the outcome of the procedure. • Change of mind or decision to discontinue treatment. • Complications, side effects, or allergic reactions. • Any unforeseen or unexpected results. The Client waives any right to dispute or attempt to reclaim deposits or payments via chargebacks, legal claims, or third-party intervention. 5. ACKNOWLEDGMENT & INFORMED CONSENT By proceeding with the procedure, the Client acknowledges that: • They have read, understood, and voluntarily agreed to the terms of this Agreement. • They have been given the opportunity to ask questions and have received satisfactory answers. • They fully accept all risks and potential complications associated with the procedure. • They acknowledge that this Agreement is legally binding and enforceable in any jurisdiction.
Client Digital Signature