MERAKI MED SPA INFORMED CONSENT FORM

1. General Acknowledgment

I, the undersigned, voluntarily consent to receive medical treatments and procedures at MERAKI MED SPA, located in Coral Gables, Florida. I acknowledge that these services are elective and not medically necessary. I further understand that no guarantees or promises have been made regarding the results.I understand that these services may include, but are not limited to:

• Aesthetic treatments (e.g., Botox, dermal fillers, and microneedling)

• Laser and energy-based procedures

• Medical-grade skincare treatments

• Wellness services (e.g., IV hydration, weight loss support)

Treatments will be performed by licensed and appropriately certified healthcare professionals, including but not limited to physicians, physician assistants, advanced practice registered nurses, or other certified practitioners as permitted by Florida law and under appropriate physician supervision.

2. Nature of Treatment and Alternatives

The purpose, nature, benefits, risks, and alternatives of the proposed treatment(s) have been explained to me. I understand that:

• All treatments are elective and not medically necessary.

• Alternative treatment options or non-treatment have been presented.

I have been given an opportunity to ask questions and have received answers to my satisfaction.

3. Risks and Potential Complications

I acknowledge that all medical treatments carry inherent risks, which may include but are not limited to:

• Temporary bruising, swelling, or redness

• Allergic reactions or hypersensitivity

• Burns, scarring, or pigmentation changes

• Vascular occlusion or nerve injury (rare)

• Infection or delayed healing

• Dissatisfaction with aesthetic results

I acknowledge that these risks, though rare, may result in long-term effects or require further medical intervention.

I further understand that unforeseeable complications, including severe or life-threatening conditions, may occur despite appropriate care.

4. Patient Obligations and Responsibilities

I agree to provide a complete and accurate medical history, including:

• Current and past medications (including over-the-counter and supplements)

• Allergies and sensitivities

• Chronic medical conditions and prior surgeries

• Pregnancy or breastfeeding status (if applicable)

I understand that withholding information may increase my risk of complications, for which I accept full responsibility.

I agree to follow all pre-treatment and post-treatment instructions provided by the Practice.

5. No Guarantee of Results

I acknowledge that aesthetic outcomes are subjective and dependent on individual anatomy, response to treatment, and other factors. While the Practice aims to achieve optimal results, no specific outcome is guaranteed.

6. Liability Waiver and Assumption of Risk

To the fullest extent permitted by Florida law, I voluntarily assume all risks associated with my treatment and agree to release and hold harmless Your MERAKI MED SPA, its physicians, practitioners, employees, and agents from any and all liability for injuries, complications, or dissatisfaction arising from my treatment, except in cases of gross negligence or willful misconduct.

7. Binding Arbitration Agreement

I agree that any dispute, claim, or controversy arising out of or relating to my treatment or care at MERAKI MED SPA, including claims of medical malpractice, shall be resolved exclusively through binding arbitration in Miami-Dade County, Florida.

Arbitration will be conducted under the rules of the American Arbitration Association. I understand that by agreeing to arbitration, I am waiving my right to a trial by jury or to participate in a class-action lawsuit.

8. Emergency Protocols

I understand that in the event of a medical emergency, the Practice will contact emergency services and transfer me to an appropriate medical facility. I am responsible for all associated costs.

9. Confidentiality and Privacy

All information related to my treatment will be maintained in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and Florida privacy laws. My photographs, medical records, and treatment details will remain confidential unless I provide explicit written authorization for their use.

10. Financial Responsibility

I understand and agree to the following:

• I am responsible for full payment of services at the time of treatment.

• Refunds are not provided for completed treatments, unless a medical necessity is determined by the Practice.

• I have reviewed and agree to the Practice’s cancellation and refund policies.

11. Florida-Specific Compliance

I acknowledge that all treatments comply with Florida laws and regulations, including appropriate physician supervision for treatments requiring medical oversight.

12. Informed Consent and Acknowledgment of Understanding

By signing this document, I confirm that:

• I have read and understand this consent form.

• I have had the opportunity to ask questions and have received satisfactory answers.

• I understand the nature, risks, and benefits of the proposed treatments.

• I consent to treatment and release the Practice from liability as outlined above.