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EMSCULPT Consent Form

Birthday
  • You are scheduled for a series of non-invasive treatments with the EMSculpt. The device is used for improvement of abdominal tone, strengthening of the abdominal muscles, as well as toning and firming the buttocks.   

  • Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 4. The treatment is typically 30 minutes per session, with sessions separated by at least two 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 recommended. On the day of treatment, you are advised to wear comfortable clothing which allows flexibility for correct positioning during the treatment. You will be asked to remove all metallic accessories and electronics devices.

  • I acknowledge that a 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.

  • The treatment does not require anesthesia. During the application, you will feel intense muscle 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.

Please answer whether you currently have or have had any of the following. Select all that applies:*
Are you currently pregnant or nursing? This treatment can not be performed on pregnant or nursing women.
Yes
No
Have you given birth?
Are you satisfied with the strength of your core muscles?
Are you satisfied with the shape of your buttocks?
Malibu Mini Sculpt Session 10% of proceeds donated to Susan G Koman Foundation!
Date
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