Client Information and
Slim-Massage, Radio Frequency, Vacuum-RF, Fat Cavitation, or LipoLiquify-Laser
Welcome to HealthyRayz treatments for improved health, massage, relaxation, improved skin elasticity, fat eradication and cellulite smoothing.This program can help you not only live a healthy, active life,
it will also help you attack excess fat, cellulite, sagging or loose skin, poor skin circulation, and
lymphatic toxic build-up. To achieve maximum results, follow a proper diet, and regular exercise.
Home Phone______________________________ Cell Phone____________________________
Age_______ Date of Birth __________________________ email:__________________________
Relative not living with you_____________________________phone #______________________
Currently, are you under the active care of a physician? □ No □ Yes
If “Yes”, condition:
Current medications & herbs_______________________________________________________
Certain contraindications apply to these treatments, for your health and safety.
The following conditions will exclude you from currently having any of the above mentioned treatments. Please respond to the following items with yes or no, if you have any of the following conditions:
□ No □ Yes Deep vein thrombosis, thrombophlebitis (phlebitis)
□ No □ Yes Recently diagnosed with or in treatment for malignant cancer (within 2 years)
□ No □ Yes Pregnancy
□ No □ Yes Hemophilia
□ No □ Yes Uncontrolled high blood pressure
□ No □ Yes Multiple sclerosis
□ No □ Yes Lymphedema
□ No □ Yes Epilepsy
□ No □ Yes Open wounds in or near areas of treatment
□ No □ Yes Heart Disease or with Heart Pacemaker
□ No □ Yes Kidney or Gall-stone diseases
□ No □ Yes Embedded metal objects or silica gel
□ No □ Yes Body condition of frequently overheating or taking on too much inner heat
□ No □ Yes Gastric hypersensitivity
□ No □ Yes Recent abdominal, intestinal or stomach operation (within 6 weeks)
Warning: If you have the following conditions, the above listed treatments should only be administered with caution.
A note from your physician allowing the treatments may be required.
Please respond to the following items with yes or no, if you have any of the following conditions.
You may not be able to receive some treatments under certain conditions.
□ No □ Yes Using prescribed anti-coagulant drugs (Coumadin, heparin, aspiring based products)
□ No □ Yes Cancer (not recent – past 2 years)
□ No □ Yes Diabetes
□ No □ Yes Epilepsy
□ No □ Yes Eating disorder
□ No □ Yes Fascitis, Tendonistis in areas to be treated
□ No □ Yes Belly button or body piercings
□ No □ Yes Bone fractures (unhealed, bone deformities, or metal implants)
□ No □ Yes Heart Pacemaker/diagnosed heart condition, circulatory problems
□ No □ Yes Hernia (previous hernia, or hernia surgery)
□ No □ Yes High blood pressure (140/100 or above)
□ No □ Yes Circulatory or Heart problems
□ No □ Yes Mesh surgery repair (not recent – past 6 months)
□ No □ Yes Menses active, emiction or incontinence period
□ No □ Yes Recent scarring on areas to be treated
□ No □ Yes Skin disorders (open sores, abrasions, infections, severe inflammation, psoriasis)
□ No □ Yes Skin that is extremely sensitive or bruises easily
□ No □ Yes "Spider" veins in areas to be treated
□ No □ Yes Surgical procedures (prior 6 weeks including Cesarean Section or 2 weeks liposuction)
□ No □ Yes Systemic infections (including swollen glands)
□ No □ Yes Varicose veins in areas to be treated
□ No □ Yes Any other short-term chronic illness or conditions (specify):
1. □ I have met with my technician to discuss treatment options. I fully understand the information regarding the treatment systems
I elect to have.
2. □ I have been given the opportunity to have all my questions answered with regard to any of the treatments I elect to have.
3. □ I authorize and give consent to allow the technician to administer the following treatments upon me:
□ Synergie AMS Slim-Massage □ LipoLight □ Radio Frequency Skin Tightening
□ Radio Frequency and/or Vacuum Radio Frequency Fat Cavitation
4. □ I am aware that individual results may vary and no guarantees or promises have been made between the technician or consultant and myself.
5. □ I understand that my information or results will not be published without prior consent.
6. □ I understand that these treatments may involve certain minor risks (ie: bruising, redness, burning, sensitive reaction)
and I fully accept all responsibilities regarding these risks.
7. □ I acknowledge and consent to be photographed for purposes of treatment monitoring and progress evaluation.
8. Check one of the following boxes:
□ I have reviewed the contraindications portion of this form and I am not subject to any of those conditions which
would exclude me from treatments.
□ I have provided a doctor’s approval note to allow me to receive treatments.
9. □ I have answered truthfully all questions on this form.
Client’s Signature: ______________________________________________ Date: __________________
Client Printed Name:_______________________________________________
Doctor’s Signature:___________________________________________ Date:___________________
Doctor’s Printed Name:_________________________________________