Unfiltered Body Contouring (EMT & Body sculpting) pre screening & consent form Name * First Name Last Name Phone (###) ### #### Email * Age * Overview * You are scheduled for a series of non-invasive treatments with Unfiltered EMT (muscle enhancement and fat reduction) and/or Unfiltered Body Sculpting, which includes a customized combination of radiofrequency (RF), ultrasonic cavitation, and laser lipo. These technologies are designed for non-invasive lipolysis (fat breakdown), reduction in abdominal circumference (for Skin Types I–III), and overall body contouring. Unfiltered EMT is also cleared for improving abdominal tone, strengthening abdominal muscles, and developing a firmer abdomen. It additionally supports the strengthening, toning, and firming of the buttocks, thighs, calves, and arms. Your provider will customize your treatment plan based on your goals. Each session lasts anywhere from 30 - 60 minutes and sessions will be spaced out according to your technician's guidance. Completing a full treatment series is essential for achieving the best outcome, and additional sessions may be advised for enhanced or ongoing results. There is no special preparation required prior to treatment, but maintaining proper hydration is strongly encouraged. On the day of your appointment, please wear active wear to your EMT sessions, and undergarments to your Body Sculpting sessions to allow for proper positioning during your session. You will be asked to remove all metallic accessories and electronic devices before treatment begins. I accept Current Weight Height Which areas would you like to improve * Core Muscle Strength Shape of Buttocks Tone of Arms Tone of Legs Whats your current lifestyle like in terms of activity & food intake like? * Please check all * 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 and increase your protein intake to help promote and maintain results I understand that 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.) Do you have any of the following? * If you say yes to any of the following, you will NOT be cleared for this treatment. Metal or electronic implants Cardiac pacemakers and/or implanted defibrillators and/or implanted neurostimulators Drug Pumps Pulmonary insufficiency Malignant Tumor Cardio diseases Disturbance of temperature or pain perception Septic conditions and empyema Acute inflammations Systematic or local infection such as osteomyelitis and tuberculosis Contagious skin disease Elevated body temp Pregnancy Post Partum period and/or nursing Basedows disease Hemorrahgic conditions Heart disorders Epilepsy Recent surgical procedures Areas of the skin which lack normal sensation None of the above Contraindications * 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 as is the case with every heat-based therapy, in rare cases, an occurrence of localized overheating of tissue cannot be excluded 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. I understand that there are certain risks associated with Unfiltered EMT treatments I understand risks may 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 I I understand that the treatment over injured or otherwise impaired muscles is contraindicated 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 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 Women: Have you been pregnant? Yes No Photo Consent * I agree to before and after treatment photos, measurements and weigh ins as this will help for medical evaluation of the results of the treatment. I consent I also consent to before & after photos to be posted Consent * 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 EM NEO by the staff at Unfiltered Beauty and his/her designated staff I understand that this consent is for current and all future EM NEO treatments at Unfiltered Beauty Disclaimer * I understand that Cavitation, RF, and laser lipo are not weight loss procedures but body contouring aids. I also understand that EMT/HIEMT uses high-intensity electromagnetic energy and may cause muscle fatigue similar to post-workout soreness. I understand Consent Duration * I understand that this consent is for current and all future Body Contouring including but not limited to: muscle enhancement, fat reduction & body sculpting treatments at Unfiltered Beauty I agree My electronic signature below indicates that the above information is accurate and current * Write your full name First Name Last Name Thank you!
