Unfiltered Body sculpting & EMTpre screening & consent form Name * First Name Last Name Phone (###) ### #### Email * Age * Overview * You are scheduled for a series of non-invasive body treatments with Unfiltered EMT (for muscle enhancement and fat reduction) and/or Unfiltered Body Sculpting, which combines technologies such as radiofrequency (RF), ultrasonic cavitation, and laser lipo. These modalities are designed to support non-invasive fat breakdown (lipolysis), reduction in abdominal circumference (for skin types I–III), and overall body contouring. Unfiltered EMT is also FDA-cleared to improve core strength, tone abdominal muscles, and firm the midsection. It may also help strengthen, tone, and sculpt the glutes, thighs, arms, and calves. Your treatment plan will be personalized based on your goals and will be spaced out according to your technician’s professional guidance. Each session typically lasts 30–60 minutes, and completing a full treatment series is essential to achieve optimal results. Additional sessions may be recommended for continued progress or maintenance. No special preparation is required beforehand, but staying well hydrated is strongly advised. Please arrive in activewear for EMT sessions and wear undergarments to your Body Sculpting appointments to allow for proper positioning. All metallic accessories and electronic devices must be removed before your treatment begins. I accept Current Weight Height Unfiltered EMT - Which areas would you like to improve Abs Glutes Biceps Triceps Hamstrings Quads Calves Unfiltered Body Sculpting - Which areas would you like to improve Stomach & Flanks Lower back & love handles Cellulite (back of legs) Arms Bra Fat Thighs Other 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 understand that there are certain risks associated with Unfiltered Body Sculpting and 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 Medications etc. Please list any current medications or supplements, and any medical conditions not mentioned above that your technician should be aware of. Women: Have you been pregnant? Yes No Client Commitment & Aftercare * I understand that results are influenced by lifestyle factors such as hydration, physical activity, and nutrition, and I agree to follow all pre- and post-care instructions provided by my technician. I agree Media 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 to photos/videos being taken for my personal profile I also consent to before & after photos/videos to be posted Procedure Consent & Client Responsibility * 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 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 have read the above information, and I request and give my consent to be treated with Unfiltered Body Sculpting and/or EMT by the staff at Unfiltered Beauty and his/her designated staff I understand that this consent is for current and all future Unfiltered Body Sculpting and/or EMT treatments at Unfiltered Beauty Rescheduling Policy * At Unfiltered Beauty, appointment times are thoughtfully reserved just for you. To reschedule your appointment, I require a minimum of 7 days’ notice. This allows me to offer your spot to another client and maintain a smooth booking experience for everyone. If you request to reschedule with less than 7 days’ notice, a rebooking fee will apply. If you request to reschedule with less than 48 hours' notice, you will be charged 50% of your original service. To secure a new time slot, you’ll be asked to pay the rebooking fee or full amount upfront, depending on the timing of the change. These policies apply regardless of the reason for rescheduling, including work conflicts, illness, transportation issues, or weather, as each appointment is carefully scheduled in advance. Thank you for valuing the time and care that goes into preparing for your service. I understand & I agree Late Arrival Policy * At Unfiltered Beauty, each appointment is carefully reserved to ensure you receive the full attention and service you deserve If you arrive a few minutes late, a one-time grace period will be offered. If you are 10 minutes late to any future appointments, a $25 late fee will apply. If you arrive 15–20 minutes late and I am still able to accommodate you: • Your service time will be shortened to stay on schedule • A $75 extended time fee will automatically apply for appointments longer than 1 hour If you arrive more than 20 minutes late, your appointment will be cancelled and you will be charged 50% of the full service cost. To rebook, you must pay the full cost of a new appointment. These charges apply regardless of the reason — including traffic, parking, or difficulty finding the studio — as appointment slots are booked exclusively for each client. Thank you for understanding and respecting my time and the commitment I make to every client! I understand & I agree My electronic signature below indicates that the above information is accurate and current * Write your full name First Name Last Name Date MM DD YYYY Thank you!
