I agree that all the above information is true and accurate to the best of my knowledge.

I. I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness and bruising may occur.

II. I understand that tanning beds, pools, some skin care products and medications can affect my skin.

III. I have been quoted the cost of today’s procedure, and the cost of next procedures.

IV. I release the practitioner of any and all liability for any harm that may unintentionally occur during my treatments(s).

V. I understand that the anticellulite treatment that I am given is for the purpose of cellulite reduction and improving circulation. I understand that a technician neither diagnoses illness, disease, or any other medical, physical or mental disorders, nor performs any spinal manipulations. I’m responsible for consulting a qualified physician for any physical ailment I may have.

I certify that I have read and have had read to me to consents of this form. I understand the risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me, and I authorize my Specialist / Technician to perform on my body the Anticellulite treatments (by vacuum cupping and bamboo sticks) procedure desired today.

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