Kabir Center For Health - EmSculpt NEO Inatke Form

GENERAL PATIENT RECORD
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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*
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*
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*
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*
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*
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*

Treatment considerations
I am aware that the treatment cannot be applied over the head, heart and neck. Initials*
I am aware that pregnancy is contraindicated, and pregnant women cannot undergo the treatment. Initials*
I am aware that as is the case with every heat-based therapy, in rare cases, an occurrence of localized overheating of tissue cannot be excluded. Initials*
I am aware that the applicators must be in full contact with the bare skin. I am aware that no therapy can't be performed through clothing. Initials*
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, increased menstrual flow in female patients and panniculitis*. 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. I fully understand the treatment conditions, the procedure, and possible side effects. Initials*
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*
My signature below indicates that the above information is accurate and current.
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PHOTO / VIDEO RELEASE
I grant the rights of my image, in video or still, and of the likeness and sound of my voice as recorded on audio or video tape. I agree that there will be no direct payment, royalties or other compensation offered to me by the company arising or related to the use of my image or recording. I understand that my image may be edited, copied, exhibited, published or presented in presentation under any legal condition, including but not limited to: marketing, illustration, medical and scientific publication, social media, and web content. Furthermore, I waive the right to inspect of approve the finished product wherein my likeness may appear. I also understand that this material may be used within an unrestricted geographic area.

I also understand that I may revoke this photo / video release at any time by notifying PROfunctional Chiropractic in writing withing 48 hours of capture. The revocation will not affect any actions taken before the receipt of this written notification. Images / videos will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.

By signing this release, I acknowledge that I have completely read and fully understand the above consent for procedure and image release and agree to be bound thereby. I hereby release any and all claims against any person or company utilizing this material in compliance with the aforementioned restrictions.
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Treatment & ReactionBefore & After PhotosTestimonialPlease exclude my face
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HIPAA CONSENT FORM
Kabir Center for Health & Rehabilitation

“Change your Habits, Change your Health, Change your Life!”

2412 E. Washington St. Ste. 9A, Bloomington, IL 61704

Office 309-663-7011 Fax 309-663-4806

www.kabircenter4health.com

PATIENT HEALTH INFORMATION CONSENT FORM

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPPA NOTICE that is available to you at the front desk before signing this consent.

1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.

2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.

3. A patient’s written consent need only be obtained one time for all subsequent care given the patient in this office.

4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of these records for the care given proper to the written request to revoke consent but would apply to any care given after the request has been presented.

5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.

6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.

7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.

I give permission to the following individuals to have information regarding my medical condition or billing and insurance information
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I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.
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GENERAL PATIENT RECORD

PHOTO / VIDEO RELEASE

HIPAA CONSENT FORM