Body Contouring Agreement *

I understand Body contouring does not treat medical conditions nor does it claim or guarantee to treat or relieve any medical condition. • Body contouring should not be used on those with cardiac issues. • Body contouring should not be applied across or on thoracic cavity • Body contouring should not be applied carotid sinus nerves. • Body contouring should not be applied over inflamed, infected or swollen areas of the skin. • Body contouring should not be applied over or near cancerous areas. I understand that any procedure involves risk. Risk may include redness, swelling, irritation, skin reaction, or increased heart rate.

Yes

No

Medical History *

Anyone suffering from the following would NOT be suitable for this treatment: - Pregnant - HIV-AIDS - active cancer - hepatitis C/D - heart disease (not under the control of a physician) - heart/pacemaker - autoimmune disease (not under the control of/or monitored by a physician) - thyroid problems (not controlled by medication) I have been honest and forthright about my medical history, and am healthy to use the device. I am not pregnant, have any metallic implants (including a pacemaker), nor any other disease or condition that maybe negatively impacted by the Body Contouring device.

Yes

Acknowledgement *

I understand each person has a different response to the Body Contouring treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and receive satisfactory responses. I voluntarily provide my consent to partake in the Body Contouring treatment. Should any pain or discomfort occur I will immediately notify The Fitness Empire staff. I will not hold The Fitness Empire liable for any irritation or effects of having thermal heat applied during the Body Contouring therapy.

Yes

Name *

First Name

Last Name

Date *

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