Emsculpt General Patient Record

Patient's Name*

First NameLast Name

Phone Number*

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Date Of Birth*

Date

Email*

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You are scheduled for a series of non-invasive treatments with the EMSCULPT NEO®.
EMSCULPT NEO is indicated to be used 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.

• Non-invasive lipolysis (breakdown of fat) of the abdomen.

• Reduction in circumference of the abdomen.

• Non-invasive lipolysis (breakdown of fat) of the thighs.

• Reduction in circumference of the thighs.

• EMSCULPT NEO is intended for use with skin types I – VI.

• Non-invasive lipolysis (breakdown of fat) of the flanks limited to skin types I - IV.

• Non-invasive lipolysis (breakdown of fat) of the upper arms limited to skin types II and III and BMI 30 and under.

The EMSCULPT NEO device is intended to be used under medical supervision for adjunctive therapy for the treatment of medical diseases and conditions.

The EMSCULPT NEO device is indicated for use in stimulating neuromuscular tissue for bulk muscle excitation in the legs or arms for rehabilitative purposes.

Indications for Use for Muscle Stimulators:
• Relaxation of muscle spasms
• Prevention or retardation of disuse atrophy
• Increasing local blood circulation
• Muscle re-education
• Immediate post-surgical stimulation of calf muscles to prevent venous thrombosis
• Maintaining or increasing range of motion

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

	Yes	No
Pregnancy
Cardiac Pacemakers
Implanted defibrillators
Electronic Implants
Drug Pump
Hemonthagic Conditions
Anticoagulation Therapy
Heart Disorder
Malignant Tumor
Fever
Allergies To Medications
Any Surgeries
Any Skin Disease

I am aware that I can’t undergo the treatment when menstruating.

▪ I understand there are certain risks associated with BTL EMSELLA treatments and they include but
are not limited to: muscular pain, temporary muscle spasm, temporary joint or tendon pain, local
erythema or skin redness. I understand that the treatment may involve risks of complications or injury
from both known and unknown causes, and I freely assume these risks.

▪ I am willing to fill in forms and/or anonymous questionnaires if requested, as this will help for medical
evaluation of the results of the treatment. Information will be acquired for medical records or marketing
purposes.

▪ I understand the results may vary from person to person and that an exact result cannot be predicted.
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 BTL
EMSELLA procedure by the physician(s) in the below stated practice and his/her designated staff.

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