NewYou Medical EMSCULPT CONSENT FORM

You are scheduled for a series of non-invasive treatments with the EMSCULPT. 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 VI. The device is also 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. 

Your treatment provider will discuss your specific treatment needs. The recommended number of treatments is 4 or more. The treatment is typically about 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. 

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. Avoid lotions and oils to the treatment area prior to your appointment. 

I acknowledge that a successful treatment outcome can be affected by smoking or excessive alcohol consumption and eating disorders or some medications. While no special diet is required, you are encouraged to eat healthy to help promote and maintain results. 

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. 

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

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

▪I am aware that the treatment cannot be applied over the head, heart and neck.

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

▪I am aware that the applicators must be in full contact with the bare skin. I am aware that the therapy can't beperformed through

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 leading to possible blister, erosion and rarely scar, increased menstrual flow in female patients and

I understand that the treatment over injured or otherwise impaired muscles, including hernias particularly with mesh, is

I understand I need to inform the treating professionals immediately if I feel increased discomfort and intense heat in any area.

▪I understand that the treatment may involve risks of complications or injury from both known and unknowncauses, and I freely

 

▪I agree to before and after treatment photographs and weighing, as this will help for medical evaluation of the results of the treatment. We will not use your photographs for marketing purposes unless we specifically have you sign a release form for use of photographs.

 

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. 

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 with the EMSCULPT By NewYou Medical Inc in this practice and his/her designated staff. 

 

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