Emsculpt

{ binding firstError.message }
{ binding firstError.message }

You are scheduled for a series of non-invasive treatments with the Emsculpt. The device is indicated for improvement of abdominal tone and strengthening of the abdominal muscles same as for strengthening, toning and firming of buttocks.

{ binding firstError.message }

Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 4. The treatment is typically about 30 minutes per session, with sessions separated by at least 2 days, depending on your needs. Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments depending on your condition.

{ binding firstError.message }

Prior to the treatment you are not required to do anything special. On the day of the treatment, you are advised to wear comfortable clothing which allows flexibility for correct positioning during the treatment. You will be asked to remove all jewelry and electronic devices.

{ binding firstError.message }

I acknowledge that 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 results.

{ binding firstError.message }

There is typically no pain associated with your treatment and there is no anesthetic required. During the application you will feel intense, yet not painful 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 treatment.

{ binding firstError.message }

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

Metal or electronic implants {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Cardiac pacemakers, implanted defibrillators,  implanted neurostimulators {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Drug pumps {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Pulmonary insufficiency {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Malignant tumor {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Fever {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Sensitivity or allergy to latex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Haemorrhagic conditions {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Anticoagulation therapy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Heart disorders {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Epilepsy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Recent surgical procedures (muscle contraction may disrupt the healing) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Areas of the skin which lack normal sensation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Have you been pregnant? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Are you satisfied with the strength of your core muscles? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Are you satisfied with the shape of your buttock? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

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

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

{ binding firstError.message }

I am aware that pregnancy and nursing are contraindicated, and pregnant women cannot undergo the treatment.

{ binding firstError.message }

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 tend on pain and local erythema or skin redness.

{ binding firstError.message }

I understand that the treatment may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks.

{ binding firstError.message }

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.

{ binding firstError.message }

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.

{ binding firstError.message }

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.

{ binding firstError.message }

I have read the above information, and I request and give my consent to be treated with the Emsculpt by the physician(s) in this practice and his/her designated staff.

{ binding firstError.message }

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

{ binding firstError.message }
{ binding firstError.message }

Emsculpt

Emsculpt

Patient First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Patient Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

You are scheduled for a series of non-invasive treatments with the Emsculpt. The device is indicated for improvement of abdominal tone and strengthening of the abdominal muscles same as for strengthening, toning and firming of buttocks.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 4. The treatment is typically about 30 minutes per session, with sessions separated by at least 2 days, depending on your needs. Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments depending on your condition.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Prior to the treatment you are not required to do anything special. On the day of the treatment, you are advised to wear comfortable clothing which allows flexibility for correct positioning during the treatment. You will be asked to remove all jewelry and electronic devices.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

I acknowledge that 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 results.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

There is typically no pain associated with your treatment and there is no anesthetic required. During the application you will feel intense, yet not painful 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 treatment.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

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

Metal or electronic implants {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Cardiac pacemakers, implanted defibrillators,  implanted neurostimulators {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Drug pumps {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Pulmonary insufficiency {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Malignant tumor {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Fever {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Sensitivity or allergy to latex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Haemorrhagic conditions {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Anticoagulation therapy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Heart disorders {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Epilepsy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Recent surgical procedures (muscle contraction may disrupt the healing) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Areas of the skin which lack normal sensation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If yes to any of these questions, please specify: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you been pregnant? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Are you satisfied with the strength of your core muscles? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are you satisfied with the shape of your buttock? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

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

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

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

I am aware that pregnancy and nursing are contraindicated, and pregnant women cannot undergo the treatment.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

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 tend on pain and local erythema or skin redness.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

I understand that the treatment may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

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.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

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.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

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.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

I have read the above information, and I request and give my consent to be treated with the Emsculpt by the physician(s) in this practice and his/her designated staff.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

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

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }