Which treatment are you interested in having?

Have you used any of the following in the past 30 days?

Tanning bed
Self- tanning cream
Sun tanning

Check any of the following if it applies to you

General medical questions

Laser Lipo / Cavitation/ Fat freeze


The Multi-functional Cryolipolysis Machine with 40K cavitation, body RF, and lipo laser can help to
remove fat/ cellulite. Everyday lifestyle, diet and lack of exercise can influence production of fat and the
body appearance. Treatments using this system will not cure any medical conditions or alter the natural
production of fat to your body.


Laser Lipo / Cavitation/ Fat freeze Consent

Radio Frequency and skin tightening

Radio frequency technologies are used to tighten and induce collagen production for skin tightening,
wrinkle reduction, acne scarring and to minimize pores.
The radio frequency produces two or three currents depending on whether it is bipolar/ tripolar/
multipolar which alternate high and low frequency currents no less than a thousand times per second.
This heats the deeper skin tissues to promote blood circulation to tighten the skin. At the same time, the
cooling measures are taken on the skin surface by applying cooling ultrasound gel.
The purpose of the treatment is to achieve improvements in the appearance of the skin. The dermal
layer of the skin becomes thickened, with the new collagen production and the wrinkles are pushed out,
so the skin becomes firmer, and the contours are lifted.

Radio Frequency and Skin Tightening Conesnt

I have read the information above, I understand and accept this informed consent.

Terms and Conditions and Other Consents

I Hereby authorize Elite Spa (Elite Rejuvenation Center INC) to treat me using Multi-functional Cryolipolysis
machine with 40K cavitation, body RF, and Lipo Laser. Elite Muscle Toning, Hydrofacial, HIFU, pressotherapy and
Endospheres machines.
I agree to follow the post treatment recommendations advised by the operator/company and or its
representatives in order to ensure the best possible results. I understand that after the treatment within 24 hours
I will need to exercise for at least 10 minutes to help fat leave the bod through the lymphatic system. I will also
drink at least 1.5 liters of water to help flush the fat to get maximum results. I agree to co-operate with the
recommendations of the company or its representatives while I am under their care, furthermore, I do understand
that lack of co-operation from my side could result in less than optimum results.
I understand that the removal of fat or skin tightening is a very effective cosmetic procedure. Although we can
achieve great results, absolute success is a variable and cannot be guaranteed. Multiple treatments may be
necessary to achieve the best results.
I have been informed about alternative treatment possibilities and I understand that other forms of treatment or
no treatment at all, are choices that I have.
I understand that there are certain risks associated with light and cryo treatment and they include but are not
limited to the following:
Although uncommon the above treatments may cause bruises, swelling and temporary redness to the surface of
the skin.
I agree to inform the above company/ operator immediately if any adverse effects occur. I agree to photographic
documentation of the treated area prior to treatment.
I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the
opportunity to ask questions and these questions, and these questions have been answered to my satisfaction. I
fully understand the treatment conditions and procedures.
I agree to pay for the above-mentioned services and understand that there will be no refunds for any performed
services. This consent form and cost covers above selected treatments only. Additional treatments can be added to
this consent form and will be charged for as per clinic price list, including single session.
I have been made aware of the risks and I accept these terms and conditions as part of my treatment. We, the
company, operator, or its representatives accept no liability for any of the above side effects. By accepting this, I
agree to the terms and conditions and in the event of any of the above. I or any of my representatives will not
pursue Elite Rejuvenation Center INC in any means of compensation.

Terms and Conditions and Other Consents


By engaging Elite Rejuvenation Center INC (for the purposes hereof referred to together herein as the
“Company”) to provide Endosphères Therapy and related services (“Services”) and using the Company’s
equipment and facilities in relation thereto, I hereby acknowledge on behalf of myself, my heirs,
personal representatives and/or assigns, that there are certain inherent risks and dangers associated
with receiving Services and my use of the Company’s equipment and facilities. At all times, I shall comply
with all stated and customary terms, posted safety signs, rules, and verbal instructions given to me by
staff. If in the subjective opinion of the Company’s staff, I would be at physical risk in receiving Services, I
understand and agree that I may be denied access to Services until I furnish the Company with an
opinion letter from my medical doctor, at my sole cost and expense, specifically addressing the
Company’s concerns and stating that the Company’s concerns are unfounded. I hereby (1) agree to
assume full responsibility for any and all injuries or damage which are sustained or aggravated by me in
relation to my receiving of the Services, (2) release, indemnify, and hold harmless the Company, its
direct and indirect parent, subsidiary affiliate entities, and each of their respective officers, directors,
members, employees, representatives and agents, and each of their respective successors and assigns
and all others, from any and all responsibility, claims, actions, suits, procedures, costs, expenses,
damages, and liabilities to the fullest extent allowed by law arising out of or in any way related to the
Services, and (3) represent that: (a) I have no medical or physical condition that would prevent me from
receiving the Services, (b) I do not have a physical or mental condition that would put me in any physical
or medical danger, (c) I have not been instructed by a physician to not receive Services, (d) no warranty
or guarantee, or other assurance, has been made to me covering the results of the Services, (e) knowing
the risks involved I nevertheless chose to voluntarily request the Services. Notwithstanding the
foregoing (and by way of illustration only and not limitation), if any of the following apply to me or if I’m
unsure for any reason, I hereby acknowledge the Company’s recommendation that I consult a medical
physician before receiving Services:
• Pregnancy/breastfeeding
• Deep Vein Thrombosis
• Phlebitis
• Severe Varicose veins
• Taking anticoagulant drugs
• Irremovable piercings in the treatment area
• Active Cancer or Cancer treatments in the past five years (unless doctor’s clearance is received)
• Surgery in the past three months (unless doctor’s clearance is received)
o Please note: It’s recommended to receive doctor’s clearance even if it has been more
than three months post-surgery.
• Active eczema or psoriasis in the treatment area
• Presence of an active skin or bacterial infection
• Diastasis Recti
• Superficial implants in the treatment area
• Hernia


If you have a severe health condition not listed, we would always recommend you consult with your
physician before treatment.
In participating in the Services, you may be photographed, videoed, or otherwise recorded by the
Company for safety, monitoring, and training purposes. You hereby consent to such usage of your
imagery for all and any such purpose by the Company and hereby agree that the Company, without any
payment to you, shall in all cases be the sole owner of all intellectual and other proprietary rights
therein without any restriction whatsoever. I have read this Assumption of Risk, Waiver, and Release,
fully understand its terms, and understand that I am giving up substantial rights, including my right to
sue the Company under certain circumstances. I acknowledge that I am signing this waiver freely and
voluntarily. The term of this waiver is indefinite. I acknowledge that I have been urged to avoid bringing
valuables into and onto the Company’s facilities, and the Company shall not be liable for the loss of,
theft of, or damage to my personal property, including items left in lockers, bathrooms, or anywhere
else in the Company’s facilities. I acknowledge that no portion of any fees paid by me is in consideration
for the safeguarding of valuables.


Endosphères Therapy®

  • Endosphères Therapy®, devised and crafted in Italy, is a technology that uses an innovative Compressive
    Microvibration™ system, a treatment that, through a roller device composed of 55 silicone spheres,
    generates low-frequency mechanical vibrations. The Endosphères Therapy® method is advanced with
    the sensor system; This pressure-controlled mechanism allows it to accurately assess the amount of
    pressure applied to the type of tissue and the number of sessions already completed. The treatment is
    now available worldwide and provides clients with many benefits: reducing the appearance of cellulite,
    improving local blood circulation, enhancing lymphatic drainage, relieving minor muscle aches and
    pains, and aiding in muscle recovery post-workout.
    What you can expect:
    • Session 1 (low intensity) - The response to the first session varies amongst clients depending on
    their body; some feel immediately energized, others feel tired (those that feel tired are typically
    the ones that need it the most). What all clients can expect, however, is a lightness in the legs,
    increased urination, and an increase in regular bowel movements.
    • Sessions 2 - 4 (low intensity, typically*) - You should expect to feel restorative effects and
    experience the release of endorphins, reduction of pain, and anti-inflammatory effects inherent
    to this treatment stage(s).
    • Sessions 5 - 8 (medium intensity, typically*) - You should notice a reduction in stagnated fluids,
    particularly water retention, which can be more visible in the abdomen. Please note: If you’re
    treating cellulite, there is potential for the cellulite to appear worse after the sixth session
    because the initial six sessions are completed at a low-medium intensity and work primarily on
    pain relief, inflammation, and lymphatic drainage. The worsening of cellulite is typical and
    indicates the treatment is working well.
    • Sessions 9 - 12 (high intensity, typically*) - You should start to notice improvements in muscle
    tone, body contouring, and cellulite reduction.
    All sessions -5
    o Increased urination is a common side effect of this treatment due to moving stagnant
    fluids. ○ Temporary hyperemia (characterized by redness and a feeling of warmth) in the
    treatment area will dissipate within 1-2 hours after the treatment.
    o More sensitive clients can experience tenderness in the treated area. It’s essential to let
    the individual completing your treatment know if the intensity is too much for you.
    o Bruising should not occur if the technique is applied correctly; however, it may happen if
    you are prone to bruising.
    o You might experience tiredness and flu-like symptoms after your session; This is normal
    as the body expels toxins post-treatment (We recommend drinking plenty of water to
    alleviate these symptoms).
Endosphères Therapy®
Before I submit this form, By choosing yes, I consent I read, and feel good to receive the treatments.

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