ENDERMOLOGIE CONSENT FORM
1massage4u.com -Julian's Therapeutic Massage
D.O.B. __________________ Sex ______________
City_____________________________ State _______ Zip _______________
Phone __________________________ E‐mail _________________________________________
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.
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 above‐described treatments.
Client signature____________________________________________ Date ___________________