* Pregnancy, Recent pregnancy or breast feeding

* Heart Condition including pacemaker

* Thrombosis or Thrombophlebitis

* Anticoagulant medication

* Photosensitive medication

* Metal prosthesis or implants (area specific)

* Diabetes

* Epilepsy

* Self tan on treatment area

* Auto Immune Conditions

Inflammation or infection in the

treatment area

* Gold injections

* Haemophillia

I certify that i do not have any of the above conditions. I completely understand the implications of the treatment that I will be receiving, including the listed side effects. At no time have I been misled or badly informed by the above mentioned therapist or company. Any falsifications of information submitted by myself could be detrimental to my health and success of my treatment,

and the company will not be held liable. I have been advised that I may experience possible discomfort during the treatment. I hereby authorise and direct them to administer the prescribed process and perform such procedures as may be deemed necessary or advisable. My signature below constitutes my acknowledgement that: 

1) | have read, understood and fully agree to the foregoing and I have been informed of the post care treatment information document. 

(2) Give consent to the proposed treatment process that has been satisfactorily explained to me and I have all the information that I desire.

(3) I have eneged with the relvant patch testing requirements at least 48 hours prior to treatment.

(3) I hereby give my consent and authorisation voluntarily and release the establishment and its agents of any claims that I have or may have in the future in connection with the described treatment.