Celebrity Cosmetic Dermatologist

Prime Health Waiver of Liability and Release Form

Address: 1035 Sterling Rd, Suite 104, Herndon, VA 20170

Physician Name: Dr. Han Tonthat

Purpose of this Waiver

This waiver is designed to protect Prime Health, its staff, physicians, and affiliates from liability related to any side effects, injuries, complications, or unforeseen critical outcomes resulting from treatments provided. By signing this document, the Patient acknowledges full understanding of the risks involved and agrees to waive all claims against Prime Health.

1. Scope of Treatments Covered

This waiver applies to all treatments, procedures, and services provided by Prime Health, including but not limited to:

1. Weight Loss Treatments:

   • Medications and injections (e.g., Tirzepatide, Semaglutide, lipotropic injections).

   • Fat-reduction procedures (e.g., CoolSculpting, lipodissolving injections).

   • Customized diet and exercise plans.

   • One-on-one professional coaching and follow-ups.

2. Aesthetic and Wellness Services:

   • Skin rejuvenation, laser treatments, or other aesthetic procedures.

   • Hormonal or metabolic support injections.

3. Diagnostics and Assessments:

   • Blood work, BMI analysis, metabolism testing, and body composition measurements.

Important: All treatments are performed with the intention of improving overall wellness or achieving weight loss goals. These treatments are not designed to diagnose, treat, or cure medical conditions.

2. Acknowledgment of Risks

By signing this waiver, the Patient acknowledges and accepts that all treatments carry risks, which may include, but are not limited to:

A. Common Risks:

• Mild pain, swelling, or redness at treatment or injection sites.

• Temporary numbness, tingling, or bruising.

• Hormonal changes, mood swings, or appetite changes.

B. Serious and Rare Risks:

• Severe allergic reactions, including anaphylaxis (a potentially life-threatening reaction).

• Gallbladder issues, such as gallstones or inflammation.

• Persistent numbness, burns, blisters, or tissue damage (CoolSculpting).

• Paradoxical Adipose Hyperplasia (PAH), where fat increases rather than decreases after treatment.

• Nerve damage, organ failure, or infections requiring medical intervention.

C. Critical Outcomes (Extremely Rare):

• Major adverse reactions, such as cardiac events or stroke.

• Unexpected health complications that could result in significant medical emergencies, including fatal outcomes.

3. Waiver of Liability

I, [Patient Name], hereby release and forever discharge Prime Health, its staff, physicians, and affiliates from all claims, demands, or causes of action, including those for:

• Personal injury, side effects, or complications resulting from treatments.

• Worsening of pre-existing conditions.

• Dissatisfaction with the outcome of treatments.

• Any financial, emotional, or physical damages resulting from side effects or complications.

This waiver applies even if injuries, complications, or critical outcomes arise from negligence, errors, or omissions by Prime Health staff, except in cases of gross negligence or willful misconduct.

4. Patient Responsibility

The Patient agrees to:

1. Full Disclosure: Provide accurate and complete medical history to Prime Health before starting treatments.

2. Compliance: Follow all pre-treatment and post-treatment instructions provided by the Clinic.

3. Acknowledgment of Risks: Accept full responsibility for any adverse outcomes resulting from treatments, including significant medical emergencies.

4. Emergency Contact Information: Provide an emergency contact who may be notified in the event of a medical emergency.

5. No Guarantee of Results

Prime Health makes no guarantees regarding the success or outcomes of any treatment. Results may vary based on individual factors, including body chemistry, adherence to instructions, and pre-existing health conditions. Dissatisfaction with results does not constitute grounds for a refund or legal claim.

6. Indemnification

The Patient agrees to release, indemnify, and hold harmless Prime Health, its staff, and affiliates from any claims, demands, or liabilities arising from or related to:

Injuries, complications, or adverse outcomes resulting from treatments, activities, or services provided by Prime Health, including but not limited to medical, aesthetic, or wellness procedures.

Actions or recommendations provided during consultations or treatment sessions.

Family members or representatives filing injury-related or wrongful action claims.

Third-party claims related to complications, injuries, or adverse outcomes.

Costs incurred from medical care, treatments, or any adverse reactions resulting from the procedures or services rendered.

The Patient acknowledges that any activities, treatments, or recommendations undertaken are at their own risk and agrees that Prime Health is not responsible for any injuries, complications, or unforeseen outcomes resulting from such activities or treatments.

7. Refund Policy

The Patient acknowledges and agrees to the following refund terms:

1. Non-Refundable Services: All fees for completed services are non-refundable.

2. Health-Related Refunds: If treatments are stopped due to verified health issues, refunds will be issued only for unused treatments.

3. Payment Obligations: If enrolled in a payment plan, the Patient must complete all payments, even if they discontinue the program.

8. Emergency Contact

9. Acknowledgment and Agreement

By signing below, I confirm that:

1. I have read and understood this Waiver of Liability and Release Form.

2. I am fully aware of the risks, including serious complications and critical outcomes, and accept responsibility for any adverse events.

3. I release Prime Health from liability for any injuries, complications, or critical outcomes arising from my participation in treatments.