Vibration Plate Release Form

Name

First NameLast Name

Birthday

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Sex

MF

Occupation

Emergency Contact

How did you hear about us?

Would you like to be added to our email list for specials and discounts?

YesNo

Do you have any chronic medical conditions that we should know about?*

YesNo

If yes, please list:

Are you currently taking any medications?*

YesNo

If yes, please explain:

Do you have any allergies?*

YesNo

If yes, please explain:

Do you have type 1 or type 2 diabetes?*

YesNo

Do you have any known kidney or liver disorders?*

YesNo

Do you have photosensitivity to sun exposure?*

YesNo

Do you currently have cancer?*

YesNo

If yes, are you currently on chemotherapy?*

YesNo

Have you had cancer in the past 12 months?*

YesNo

Do you have any thyroid problems?*

YesNo

Do you have high blood pressure?*

YesNo

Do you have any cardiovascular conditions?*

YesNo

Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, or hormonal pellets?*

YesNo

If yes, please list:

What concerns would you like addressed today?

Do you want to lose body fat?*

YesNo

If yes, from what area:

Do you want to tighten skin on your body?*

YesNo

If yes, from what area:

Do you want to reduce cellulite?*

YesNo

If yes, from what area:

Please list your regular exercise habits:*

YesNo

Please describe your current dietary habits:*

YesNo

How many ounces of water do you drink daily?*

YesNo

(Female clients) Are you currently pregnant or nursing?*

YesNo

By signing below, I agree to the following:
I have completed this form to the best of my ability and knowledge. I agree to inform the
technician of any changes in the above information. I agree that I do not have any condition(s)
that would make the requested treatment unsuitable. I will inform the technician of any
discomfort I may experience at any time during my treatment to allow them to adjust
accordingly. I agree to waive all liability toward my technician and the salon for any injury or
damages incurred due to any misrepresentation of my health.

Name

First NameLast Name

Signature

Date

Whole Body Vibration Plate Machines are scientifically calibrated exercise
machines designed to force your muscles to stretch and contract
rapidly in small increments, replicating the same action which occurs during
traditional exercising. Vibration exercises use your body weight
and gravity to it’s fullest potential. Please do not use a whole body vibration plate
or any other exercise device without getting approval from
your doctor.
The device is not recommended if you are: pregnant, diabetic with complications
such as neuropathy or retinal damage, have a pacemaker,
recently underwent surgery, suffer from Epilepsy or Migraines, have herniated
disks, spondylolisthesis, spondylolysis , have cancer or tumors,
have recent joint replacements, have metal pins or plates, or have any other
concerns about your physical health.
These contra-indications do not mean that you are not able to use a vibration or
other exercise device, but it is recommended that you consult your physician first.
I understand that using a whole body vibration machine workout is a strictly
voluntary physical activity chosen by myself (the client). If at any time I experience
pain or discomfort of any kind, I agree to inform the staff immediately and/or
terminate the exercise.

Signature

Date

Check That You have Read and agree to the following:
I certify that I do not have any of the contraindications outlined above, and I
acknowledge that medical clearance is required if I have answered "YES" to any.
I understand and agree that it is my responsibility to inform Essence Beauty LLC of any condition or changes in my health, not and ongoing, which might
affect my ability to exercise safely and with minimal risk of injury.

I understand that should I feel light headed, faint, dizzy, nauseous, or experience
pain/discomfort that I will stop my session and inform *Essence Beauty LLC*.

I understand that the results of *Essence Beauty LLC*'s Vibration Therapy may
vary and cannot be guaranteed and that my progress depends on my effort and
cooperation in and outside of the sessions.
Clients under 18yrs old must have parent/guardian consent to use the the Body
Vibration Machines.

Signature

Date

Vibration Plate Release Form

Medical History