EM SCULPT CONSENT FORM

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Occupation

Agree to the following

You are scheduled for a series of non-invasive treatments with the Emsculpt. The device is indicated for improvement of abdominal tone, strengthening of the abdominal muscles, development of firmer abdomen. strengthening , toning and firming of buttockYour treatment provider will discuss your specific treatment needs. Recommended number of treatments is 4. The treatment is typically 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.Before the treatment, you are not required to do anything special, however, keeping your body well hydrated is recommended. On the day of 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 electronics devicesI 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 resultsThe 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 treatmentI 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 metallic or electronic implants (such as pacemakers, defibrillators, metallic IUDs, etc.)

Please answer whether you currently have or have had any of the following:

Metal or electronic implants:

Cardiac pacemakers, implanted defibrillators, implanted neurostimulators:

Drug pumps

Pulmonary insufficiency

Malignant tumo

Fever

Metallic IUD

Sensitivity or allergy to latex

Hemorrhagic conditions

Injured or otherwise impaired muscles

Heart disorders

Epilepsy

Recent surgical procedures (muscle contraction may disrupt healing)

Areas of the skin which lack normal sensation

If you answer YES to any of these questions, please specify:

Treatment considerations

I am aware that the treatment cannot be applied over the head, heart and neckI am aware that pregnancy and nursing are contraindicated, and pregnant women cannot undergo the treatment.I understand that there are certain risks associated with Emsculpt 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 decreases.I understand that the treatment over injured or otherwise impaored muscles is contraindicatedI understand that the treatment may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks.I agree to before and after treatment photographs, measurements and weighing, as this will help for medical evaluation of the result of the treatment. Information will be acquired for medical records or marketing purposesI understand the results may vary from person to person and that anexact result cannot be predicated. 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 results after the procedure. I acknowledge the results may not meet my expectations.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. I fully understand the treatment conditions, the procedure, and possible side effects .I have read the above information, and i request and give my consent to be treated withthe Emsculpt by the practitioner in this practice and her designated staff

I am 18 years old or older

Yes, I am 18 years old or olderNo I am not 18 years old. I have parental and/or guardians consent with a signature below

No I am not 18 years old. I have parental and/or guardians consent with a signature. By signing below you understand all of the possible risks of this service.

Print Parental/Guardians name:

first and last name

Questons Asked:

HOW LONG IS AN EMSCULPT® TREATMENT SESSION?

-treatment session lasts 30 minutes.

HOW MANY TREATMENTS WILL I NEED?

-An EMSCULPT® Clinical studies on EMSCULPT® were done as a series of 4 treatments total – twice weekly treatments for 2 weeks.*

WHAT SHOULD I EXPECT IMMEDIATELY AFTER EMSCULPT® TREATMENT?

-The area of treatment may be mildly sore, similar to a strength training workout. This may persist for a day following treatment.

REFUND POLICY:
Individual services, promotional services, sale services, series services, gift certificates purchased for yourself or
for another individual are absolutely non-refundable.
This applies to all of the procedures offered at the salon.
There are NO REFUNDS on any procedures or services we have already initiated or already completed. NO
EXCEPTIONS

My signature below indicates that the above information is accurate and current

Date

Client Signature

*All areas of treatments are priced differently.

Please ask if you have any questions or concers.