EMSCULPT 

You are scheduled for a series of non-invasive treatments with the EMSCULPT NEO. The device is indicated for non-invasive lipolysis (breakdown of fat) of the abdomen and for reduction in circumference of the abdomen in Skin Types I to III. The device is also cleared for improvement of abdominal tone, strengthening of the abdominal muscles, development of firmer abdomen. Strengthening, toning and firming of buttocks, thighs and calves. Improvement of muscle tone and firmness, for strengthening muscles in arms. Initials:   Type a label   

Your treatment provider will discuss your specific treatment needs. The recommended number of treatments is 4. The treatment is typically about 20-30 minutes per session, with sessions separated by 5 to 10 days. Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments, depending on your goals. Initials:    Type a label   Before the treatment, you are not required to do anything special, however, keeping your body well hydrated is strongly recommended. On the day of the treatment, you are advised to wear comfortable clothing, allowing flexibility for correct positioning during the treatment. You will be asked to remove all metallic accessories and electronic devices. Initials:   Type a label   

I acknowledge that a successful treatment outcome can be affected by smoking or excessive alcohol consumption and 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:   Type a label   

The treatment does not require anesthesia. During the application, you will feel intense muscle contractions and heating sensation 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:   Type a label   

I am aware NOT TO wear any metallic accessories (such as jewelry, watch or clothes containing metallic threads or metallic accessories) during the treatment. I also acknowledge that I do not have any metallic or electronic implants (such as pacemakers, defibrillators, metallic IUDs, etc.) Initials:   Type a label   

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

▪         Metal or electronic implants      Yes  No                                                                                

▪         Cardiac pacemakers, implanted defibrillators, implanted neurostimulators       Yes   No   

▪         Drug pumps                               Yes   No                                                                                    

▪         Pulmonary insufficiency                               Yes   No                                                      

▪         Malignant tumor                                    Yes   No                                                           

▪         Cardiovascular diseases                                     Yes   No                                           

▪         Disturbance of temperature or pain perception                                        Yes   No              

▪         Septic conditions and empyema                                                 Yes   No                     

▪         Acute inflammations                                                                   Yes   No                        

▪         Systemic or local infection such as osteomyelitis and tuberculosis                 Yes   No   

▪         Contagious skin disease                                                                        Yes   No   

▪         Elevated body temperature                                                                            Yes   No   

▪         Pregnancy, post-partum period, nursing and menstruation                          Yes   No         

▪         Basedow’s disease                                                                                      Yes   No   

▪         Metallic IUD                                                       Yes   No                                           

▪         Hemorrhagic conditions                                                                                Yes   No   

▪         Heart disorders                                                                                            Yes   No   

▪         Epilepsy                                                                                                 Yes   No   

▪         Recent surgical procedures (muscle contraction may disrupt the healing)       Yes   No   

▪         Areas of the skin which lack normal sensation                                        Yes   No   

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

   

Please answer the following:

▪         Have you been pregnant?C-section   Vaginal birth         

▪         Are you satisfied with the strength of your core muscles?           Yes   No                               

▪         Are you satisfied with the shape of your buttock?                           Yes   No                   

▪         Are you satisfied with the tone of your arms?                              Yes   No                   

. Are you satisfied with the tone of your calves?         Yes   No   

*For the full range of contraindications, warnings, and cautions, consult your treatment provider.

Treatment considerations:

▪      I am aware that the treatment cannot be applied over the head, heart and neck. Initials:   Type a label   

▪      I am aware that pregnancy is contraindicated, and pregnant women cannot undergo the treatment.

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▪      I am aware that the applicators must be in full contact with the bare skin. I am aware that the therapy can't be performed through clothing. Initials:   Type a label   

▪      I understand that there are certain risks associated with EMSCULPT NEO treatments and they include

but are not limited to muscular pain, intramuscular fat decrease, temporary muscle spasm, temporary joint or tendon pain, local erythema or skin redness, localized overheating, increased menstrual flow in female patients and panniculitis*. Initials:   Type a label   

▪      I understand that the treatment over injured or otherwise impaired muscles is contraindicated*

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▪      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:   Type a label   

▪      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:   Type a label   

▪      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:   Type a label   

▪      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. Initials:   Type a label   

▪      I have read the above information, and I request and give my consent to be treated with the EMSCULPT NEO by the physician(s) in this practice and his/her designated staff. Initials:   Type a label   

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