1massage4u.com -Julian's Therapeutic Massage

Name ________________________________________        

D.O.B. __________________         Sex ______________


City_____________________________   State _______ Zip _______________

Phone __________________________    Email  _________________________________________

In case of emergency call:

Name: ___________________________________        Phone  ______________________________

The following is a list of conditions that might require special attention before receiving a treatment.

Circle the appropriate answer.

Cancer or malignant tumors Yes No
Skin disorder, inflammation, eruption or infection Yes No
Acute inflammation, infections Yes No
Acute inflammation, infections Yes No
Autoimmune or infectious progressive illness Yes No
Unexplained calf pain, deep vein thrombosis, phlebitis Yes No
Pregnancy Yes No
Recent surgery and scars Yes No
Injections Yes No
Are you under any physician’s care for any condition? Yes No
Are you taking anti-coagulants, or on long term steroid treatment? Yes No

If YES, to any of the above, please explain: _______________________________________________________

1. I hereby consent to having Endermologie treatments performed on my person. I Acknowledge that this technique has been fully explained to me.

2. I have completely answered all the specific health questions.

3. I understand that the technique may involve certain risks of minor, temporary bruising and the possibilities of a sensitive reaction.

All risks have been fully explained to me and I accept them.

I understand that this waiver includes any claims based on negligence, and hereby knowingly and

voluntarily consent to the abovedescribed treatments.

Client signature____________________________________________    Date ___________________