EM Sculpt Consent Form Name * First Name Last Name Email * Phone (###) ### #### You are scheduled for a series of non-invasive treatments with the Em sculpt. The device is indicated for improvement of musclel tone, strengthening of the muscles, development of firmer muscles. Strengthening, toning and firming of buttocks, thighs and calves. Improvement of muscle tone and firmness, for strengthening muscles in arms. * Initials Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 4. The treatment is typically about 20-30 minutes per session, with sessions separated by at least two days. Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments depending on your goals. * Initials Before the treatment, you are not required to do anything special, however, keeping your body well hydrated is recommended. On the day of the treatment, you are advised to wear comfortable clothing which allows flexibility for correct positioning during the treatment. You will be asked to remove all metallic accessories and electronic devices * Initials Initials acknowledge that a successful treatment outcome can be affected by smoking or excessive alcohol consumption, as well as: eating disorders or on-going medication. While no special diet is required, you are encouraged to eat healthy to help promote and maintain results. * Initials The treatment does not require anesthesia. During the application, you will feel intense muscle contractions in the treated area. The procedure doesn’t require any recovery time. Typically, you can get back to your daily routine right after the treatment * Initials I acknowledge that the treatment should preferably be applied directly over the skin. If not, I am aware not to wear any metallic accessories (such as jewelry, watch or clothes containing metallic threads) during the treatment. I also acknowledge that I do not have any metallic or electronic implants (such as pacemakers, defibrillators, metallic IUDs, etc.) * Initials Please answer whether you currently have or have had any of the following by marking off which apply to you: * Metal or electronic implants Pulmonary insufficiency Metallic IUD Injured or otherwise impaired muscles Recent surgical procedures (muscle contr Cardiac pacemakers, implanted defibril Malignant tumor Ongoing pregnancy Heart disorders Areas of the skin which lack normal sensation Drug pumps Fever Hemorrhagic conditions Epilepsy None of the Above If I have any metal screws, implants, or other metal devices in my body, I have obtained written authorization from my healthcare providers to proceed with the treatment. * Initials If you marked off any of the above, please specify: * Are you or have you recently been pregnant? * I have not eaten within 1 hour of my appintment and will not eat for 1 hour after my appointment. * Initials I am aware that the treatment cannot be applied over the head, heart and neck. * Initials I am aware that pregnancy and nursing are contraindicated, and pregnant women cannot undergo the treatment. * Initials I understand that there are certain risks associated with Em sculpt treatments and they include, but are not limited to muscular pain, temporary muscle spasm, temporary joint or tendon pain, local erythema or skin redness and intramuscular fat decrease * Initials I understand that the treatment over injured or otherwise impaired muscles is contraindicated * Initials I understand that the treatment may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks. * Initials I agree to before and after treatment photographs, measurements and weighing, as this will help for medical evaluation of the results of the treatment. Information will be acquired for medical records or marketing purposes. * Initials I understand the results may vary from person to person and that an exact result cannot be predicted. Completing a full treatment series is necessary to maximize treatment efficacy. It is very unlikely, but it is possible that you will not feel any recognizable result after the procedure. I acknowledge the results may not meet my expectations * Initials I certify that I have read this entire document and that I agree with all provisions. I certify that I have had the opportunity to ask questions and these questions have been answered in full to my satisfaction * Initials I have read the above information, and I request and give my consent to be treated with the Em sculpt by the physician(s) in this practice and his/her designated staff * Initials Consent * My signature below indicates that the above information is accurate and current. Yes Signature * Print Name Date * Thank you!
