Client Name *

Date of Birth *

Phone Number *

Email Address *

Treatment Date *

Practitioner / Witness Name *

Untitled

Consent Version: ELURENA-CONSENT-V-LIFT-V1.0-2026

Untitled

ELURENA – V-LIFT TREATMENT CONSENT & LIABILITY FORM

Untitled

Elurena V-LIFT is a non-invasive body contouring treatment that uses infrared light, radiofrequency, suction, and massage to temporarily reduce cellulite appearance and improve skin texture. Results vary per person and may require multiple sessions.

Untitled

During or after V-LIFT treatment, you may experience:

Warmth, tingling, or mild suction during treatment.Temporary redness, swelling, or bruising may occur.Mild soreness or sensitivity in treated areas, similar to deep tissue massage.Gradual improvement may be seen over several sessions; maintenance may be required.No refunds are offered for treatments.

Do you have a pacemaker, defibrillator, or implanted electronic device? *

Yes No

Are you pregnant or breastfeeding? *

Yes No

Do you have active cancer or a history of cancer in the past 5 years? *

Yes No

Do you have metal implants in the treatment area? *

Yes No

Do you have skin conditions, infections, or open wounds in the treatment area? *

Yes No

Do you have varicose veins, vascular disorders, or blood clotting disorders? *

Yes No

Have you had recent surgery or scar tissue in the treatment area? *

Yes No

Do you use blood thinners or have bleeding disorders? *

Yes No

Do you have uncontrolled diabetes or any serious medical condition? *

Yes No

Have you disclosed your full and accurate medical history to the practitioner? *

Yes No

Are you currently taking any medication that may affect treatment safety? *

Yes No

Have you had any recent cosmetic, medical, or aesthetic procedures in the treatment area? *

Yes No

Do you understand that treatment may be refused or postponed if there is a safety concern? *

Yes No

V-LIFT Consent Confirmation *

I understand the V-LIFT treatment, possible risks, contraindications, and limitations. I understand that results are not guaranteed and that multiple sessions may be required. I confirm that I have disclosed my full medical history and give consent to proceed with V-LIFT treatment.

Untitled

I authorize Elurena and its staff to take photographs of me for documenting treatment progress and results, training, education, and marketing use. I understand my name will not be used, my face will not be shown unless I give specific permission, and I may revoke this consent in writing at any time.

Photography Progress Consent

I consent to photographs being taken for treatment progress documentation only.

Photography Training Consent

I consent to photographs being used for training and education.

Photography Marketing Consent

I consent to photographs being used for marketing, digital, print, or online purposes.

Photography Face Consent

I specifically consent to my face being shown, if required.

Treatment Information Confirmation *

I confirm that I have read and understood the V-LIFT treatment information shown in this form.

Risks and Limitations Confirmation *

I confirm that I understand the possible risks, side effects, contraindications, and limitations of V-LIFT treatment.

No Guaranteed Results Confirmation *

I understand that treatment results vary and are not guaranteed.

Multiple Sessions Confirmation *

I understand that more than one session may be required.

No Refunds Confirmation *

I understand that no refunds are offered for completed treatments.

Questions Confirmation *

I confirm that I have had the opportunity to ask questions before proceeding.

Consent to Proceed *

I consent to proceed with V-LIFT treatment.

Client Signature *

Client Signature Date *

Practitioner / Witness Signature *

Practitioner / Witness Signature Date *

ELURENA – V-LIFT Treatment Consent Form

ELURENA – V-LIFT TREATMENT CONSENT & LIABILITY FORM