Home
Contact Us
FA Products
Avazzia
>
Avazzia Information Videos
Pro-Sport Ultra & Pro Sport 3
BEST-RSI
BEST-Pro 1
Avazzia Blue
Ezzi-Lift
Ezzi-Lift with Photodynamics
BEST-Vet Pro
QRS 101 Home System
>
QRS Frequency Programs
QRS Healthy Cells
QRS 101 Homesystem Technical Data
QRS Key-Lock Principle
The Quantenmedicine
QRS 101 Video's
QRS Metabolism of The Cell:The Ion Transport
FA Test Series
>
FA-01 Gut Check Test Series for Patient
FA-01 Gut Check Test for Practitioners
FA Store
Studies & Forms
Avazzia Studies & Research Papers
GUTCHECK Test Studies & Research
QRS Studies & Research
Prescription
Rental Agreement
Waivers
Training Classes
FA Testimonal's
Consent and Release of Liability
*
Indicates required field
Name
*
First
Last
Title
*
Company
*
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone
*
Personal Information Section
Check if Yes
*
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
Lack of Sensation in Skin
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
*
Medications
*
Scars? Locations
*
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.
Please Check Below
*
I Approve Signature Field Below to stand as my legally binding signature
Signature
*
Date
*
Printed Name
*
First
Last
Witness
*
OFFICE USE ONLY
Time in
*
Time out
*
Date
*
Approved by Printed Name
*
Please check below
*
I Approve Signature Field Below to stand as my legally binding signature
Signature
*
License
*
Submit
