Radiant Vitality Client Consent Form

Consent form

MedWave & Hypervibe G17 Pro Treatment
Patient Information
Name*
Age
Date of Birth*

MonthDayYear
Gender
Email*
Phone Number*
Parent/Guardian or Emergency Contact Details
Contact Person Name*
Primary Phone Number*
Secondary Phone Number
Purpose of Treatment

You will be receiving sessions which may include:
- Hypervibe G17 Pro – Whole-body vibration therapy to assist in circulation, lymphatic drainage, muscle activation, and mobility.
- MedWave™ Red Light Therapy – Low-level laser (LLLT) therapy (635nm) to support cellular repair, reduce inflammation, and encourage natural healing mechanisms.
Potential Benefits
- Metabolic weight loss
- Improved circulation and lymphatic flow
- Reduced muscle tension and inflammation
- Enhanced recovery following injury or exertion
- Joint and connective tissue support
- General wellness and energy improvement
Contraindications / Precautions

The following conditions may make you ineligible or require physician clearance before treatment:
Do not use Hypervibe therapy if you:
- Are currently pregnant or may be pregnant
- Have active or recent cancer
- Have a pacemaker or implanted electronic medical device
- Have seizure disorders or epilepsy
- Experience frequent or severe vertigo
- Have uncontrolled diabetes or peripheral neuropathy
- Are currently taking anticoagulants (e.g., Warfarin)
- Have undergone major surgery within the last 12 weeks without physician clearance
- Have a history of heart attack or unstable cardiovascular conditions
- Have a history of deep vein thrombosis (DVT)
- Have severe osteoporosis or significant bone disorders
- Have open wounds, infections, or photosensitivity (relevant to red light therapy)
Use with caution and only under supervision if you:
- Have autoimmune disorders (e.g., lupus, multiple sclerosis)
- Have neurological conditions
If unsure, please consult with your treating healthcare provider before participating.
Thyroid medication?*
Injectable weight loss medication such as GLP-1 receptor agonists (e.g., Semaglutide, Ozempic)?*
Statin medications for cholesterol?*
Photosensitizing medications (e.g., tetracyclines, NSAIDs, chemotherapy, methylene blue)?*
If yes, written medical clearance from your treating physician may be required prior to treatment.
Health History / Specific Risk Factors

Do you have any of the following?
Photosensitive skin conditions (e.g., rosacea)?*
Medication-related muscle soreness or myopathy?*
Active skin infections, open wounds, or local inflammation?*
Gastrointestinal discomfort or reduced gastric motility?*
Recent surgery or injury in the treatment area?*
Please list all relevant medical conditions, current medications, and past surgeries below:*
Marketing Consent

Please indicate your preference
Do you consent to Radiant Vitality using my treatment results for marketing or promotional purposes*

Yes, I do consentNo, I do not consent
Acknowledgment of Understanding & Consent

By signing below, I acknowledge and understand that:
- I have been informed of the nature and purpose of both the Hypervibe G17 Pro and MedWave™ red light therapy.
- I understand the potential benefits, contraindications, and risks, including dizziness, skin sensitivity, or unexpected responses to treatment.
- I will disclose any medical concerns, and I am voluntarily choosing to participate in these sessions.
- I understand these sessions are not a replacement for medical treatment, and I should consult my doctor for diagnosis or care of medical conditions.
- I will avoid direct eye exposure to red light and agree to wear the provided protective eyewear during red light therapy.
- I understand that no refunds are available for services rendered.
Release of Liability

I hereby voluntarily assume all risks associated with the use of the Hypervibe and MedWave™ devices. I release, waive, and hold harmless Radiant Vitality, its staff, owners, agents, and affiliates from any and all claims, damages, demands, or causes of action arising from or related to participation in these sessions — whether caused by negligence or otherwise.
Patient/Parent/Guardian Signature*

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Date Signed*

MonthDayYear
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Consent form

Patient Information

Parent/Guardian or Emergency Contact Details

Purpose of Treatment

Potential Benefits

Contraindications / Precautions

Health History / Specific Risk Factors

Marketing Consent

Acknowledgment of Understanding & Consent

Release of Liability