Client Intake Form

Release and waiver: By signing below, you understand that you (on your own behalf and, if applicable, on behalf of the minor for whom you are signing) hereby permanently and irrevocably waive any and all claims and/or causes of action, in law or equity, against Micro Scalp, and also permanently and irrevocably release Micro Scalp from and any liability associated with the treatment covered by this form, including but not limited to personal injury, pain and suffering, minor or severe physical discomfort, short- or long-term side effects, temporary or permanent alteration of physical appearance regardless of severity, etc. BINDING ARBITRATION; NO JURY TRIAL. VERY IMPORTANT—PLEASE READ! I agree to arbitrate any and all disputes, claims, and/or controversies in law or equity between me and Micro Scalp arising out of, related to, or in any way connected with this form or Micro Scalp services to me. Arbitration fees, if any, shall be divided equally between me and Micro Scalp Pigmentation. If I commence a court action based on a dispute or claim without first attempting to resolve the matter through arbitration, I agree to stay the court action in favor of arbitration, and I will not be entitled to recover attorneys’ fees or costs even if such costs and fees would otherwise be available to me in arbitration or a court action. I agree that the arbitration shall be conducted in accordance with the rules of the American Arbitration Association. Judgment upon the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. The parties shall have the right to discovery as permitted by the Massachusetts Rules of Civil Procedure. By agreeing to arbitration, and by initialing below, the patient expressly agrees that he or she is agreeing to have any dispute arising out of the matters included in this “Binding Arbitration” provision decided by neutral arbitration as provided by Massachusetts law, and the patient is giving up any rights he or she might possess to have the dispute litigated in a court or before a jury. Micro Scalp Clinic takes seriously the protection of our confidential and proprietary information. By signing, you will be admitting guilt of civil conspiracy, defamation and trespassing if Micro Scalp Clinic finds out that the client is associated with a competitor and we will be filing a lawsuit against the individual and the company they are associated with. Any sessions canceled or rescheduled less than 24 hours in advance will be charged a $50 fee. This fee also includes if any patient arrives more than 30 min after their scheduled appointment time. Any no shows for sessions will be charged $75. There will be no refunds on deposits. Deposits are used for purchasing material that is unique to each individual client. Should you choose at anytime to stop treatment any funds received are non refundable . And If you choose to use the numb cream there will be a $30 charge each time it is used. I HAVE READ AND UNDERSTAND THE FOREGOING AND AGREE TO SUBMIT DISPUTES ARISING OUT OF THE MATTERS INCLUDED IN THIS “BINDING ARBITRATION” PROVISION TO NEUTRAL ARBITRATION, AND THAT BY SO DOING, I AM WAIVING MY RIGHT TO HAVE THIS DISPUTE LITIGATED IN COURT OR BEFORE A JURY. My signature attests to the fact that I have fully read this entire form, that I have had any concerns answered to my satisfaction, and that I understand and agree to the information contained within. I certify that I am a competent adult of at least 18 years of age and am either receiving the treatment described herein or am signing this form as the parent/legal guardian of a minor who shall receive the treatment described herein. This form shall apply to all subsequent treatments of a similar nature.