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Consent and Release of Liability
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Personal Information Section
Check if Yes
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Cardiac Pacemakers or other electrically powered implant
Pregnant
Cardiac Fibrillation
Recently Consumed Drug or Alcohol
Sensitivity to Electrical Current
Severe Mental Disorder
Organ Transplants
Epilepsy
Open Wounds
Phlebitis or Thrombophlebitis
Cancerous Lesions
Recent Surgery
Menstruating
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History of Fainting
History of Strokes
High or Low Blood Sugar
High or Low Blood Pressure
Botox Treatments
Have Not Consumed Water in the Past Two Hours
Other Complaints
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Medications
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Scars? Locations
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WAIVER OF LIABILITY
I understand the Avazzia device imparts electrical
frequencies into the body. I have truthfully answered the above list of contra-indications/cautions for this therapy. Avazzia does not prescribe medical treatments or diagnose. It is recommended that I see a physician for any physical ailment that I may have. I have stated all my known medical limitations. In consideration of the treatment offered to my I agree that I will not institute any suit or claim against Avaz-zia, their representatives their employees, or practitioners for any damage, loss or injury to either person or property. I am in good health and have no physical limitations which would affect my safe use of the devices. I am at least 18 years of age and otherwise legally competent to sign this agreement. This release shall be effective and binding upon me and my assigns.
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