Have you used any of the following in the past 30 days?
Check any of the following if it applies to you
General medical questions
Laser Lipo / Cavitation/ Fat freeze
Radio Frequency and skin tightening
Terms and Conditions and Other Consents
ASSUMPTION OF RISK, WAIVER, AND RELEASE
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®