• I voluntarily elect to undergo this treatment, having had the nature and purpose of fat freezing, along with the risks and hazards involved, fully explained to me by “Mary Beauty clinic”.
• I understand that there is a risk of side effects from this treatment, including but not limited to: slight pain, staining, aching, itching or numbness in the targeted area, nausea, dizziness, swelling, bruising, discoloration of the skin and muscle cramping. I understand that most of these minor side effects will reduce or go away within a few days to a few weeks after the procedure. I also understand that loss of sensation in the targeted area may last for up to a month.
• I understand that although rare, there is a risk of developing a darker skin color, hardness, discrete nodules, freeze burn, enlargement of the treated area, hernia or paradoxical adipose hyperplasia. I understand that these and any other unknown side effects may occur and I will not hold “Mary Beauty clinic” or any staff members liable.
• I understand that I may start to see changes as early as three weeks after the procedure, but I should experience the most dramatic results after 1-3months.I have been advised that my body will continue to naturally process the injured fat cells from my body for approximately four months.
• I understand that this procedure is for spot reduction of fat and is not to be used as a weight-loss solution.
• I understand that additional treatments may be needed to reach my desired outcome.
• I understand that no guarantee can be given regarding final results, and that results will vary from person to person.
• I confirm that I am not currently pregnant, lactating or trying to conceive.
• I confirmed that I am not under the influence of any drugs or alcohol.

The following conditions are recognized as contraindications for Fat Freezing treatment and must be disclosed prior to treatment:
• Pacemakers or other implanted electronic devices
• Eczema
• Psoriasis
• Bleeding Disorder
• Long term use of blood thinners
• Hernia at or near treatment site/History of Hernias
• Diabetic Neuropathy
• Using artificial heart-lung machines
• Using Portable ECG measurement equipment
• Severe cold urticaria
• Raynaud’s disease
• Any infectious disease
• Liver/heart/kidney disease
• Severe diabetes
• Numbness and/or no response to cold or heat
• Cryoglobulinemia
• Cold Agglutinin disease
• Paroxysmal Cold Hemoglobulin Uria

• I have read and understood the post-treatment home care instructions and understand how important it is to follow all instructions given to me for post-treatment care. I will consult “Mary Beauty clinic” immediately.
• The information I have provided about my medical history is accurate to the best of my knowledge, including all know allergies and/or prescription drugs/products I am currently ingesting or using topically
• I have read and fully understand this agreement and all information detailed above. I understand the Fat Freezing treatment being Performed today and accept all possible risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold “BUSINESS NAME” or the Technician performing the procedure, responsible for any of my conditions that were present, but not disclosed at the time of this treatment/procedure, which may be affected by the treatment/procedure performed today.
• This agreement will remain in effect for this procedure and all future follow-ups conducted by “Mary Beauty clinic”.

I understand that the therapist will recommend and craw the ideal shaped eyebrow however, I am free to change the shape as I desire and understand that the shape will be final and cannot be changed after the procedure.
I hereby deciare that I do not suffer from Keloid Scaring.
I hereby declare that I am not haemophiliac.
I hereby declare that I am not allergic to Iodine.
I hereby declare that I do not test positive for the HIV or Hepatitis Viruses
I hereby declare that I am not pregnant/breastfeeding
I hereby declare that I have had no Botox treatments for the past 28 days.
I hereby declare that I have had no Filler Injections for the past 3 months.
I hereby declare that I am not under treatment for Cancer/Radiation/ Chemotherapy
I hereby declare that I am aware there is NO GUARANTEE for the outcome of my procedure.
I hereby declare that I do NOT have any of the Medical Conditions that were mentioned in the above indemnity Form.
I hereby declare that I am under FULL UNDERSTANDING that the procedure is a Tattoo and a touch-up is VITAL at a reduced price.
I hereby declare that I am aware the full results will only be visible AFTER 6 WEEKS.
I authorize the use of my photographs taken by the technician to be used on social media and shown to potential clients.
I hereby declare that I have been informed, in detail about the 6D Microblading method and procedure which will be performed. I was informed that needles are used for the treatment to inject colour pigments into the upper layers of the skin.
I am aware that it is not possible to predict how durable and intensive the brow colour will be and that durability and colour intensity depend on age, skin type and environmental conditions of the treated person.
I am aware that the treatment with the pigmenting needles can cause skin irritation and minor inflammation of the skin which usually disappears within 24-36 hours.
I have been informed that the pigments will appear darker within the first 5 days.
I have been informed that the section of skin to be pigmented may be anesthetized/numbed with a surface anaesthetic.
I have been informed that medicines affect different individuals in different ways.
In some cases, side effects can occur such as allergic reactions.
I hereby declare that Aftercare procedures have been explained to me in detail and I have read the instructions given on this sheet. Furthermore, I understand the Post Procedure Instructions.

I Understand that I am responsible for notifying the beauty therapist if any of the information should change before treatment.
I confirm that the information is true to be best of my knowledge. I have been fully informed about the expected results and effects of my treatment and agree to follow all aftercare advise provided by therapist. I acknowledge that all information is confidential and will be held on file for 7 years, being solely for the purpose and use of my therapist. I hereby give my consent to proceed with treatment.
I understand and agree that all services rendered are charged directly to me and I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks.
Under fake not to make a claim against the therapist and salon and do hereby indemnify and hold the said business, its Owner and Employees harmless in respect of any claim or damage suffered by me in the consequence of undergoing the treatments procedure.