Unfiltered emt 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. The device as indicated for non-invasive lipolysis (breakdown of fat) of the abdomen and for reduction in circumference of the abdomen in Skin Types I to III. The device is also cleared 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. Your treatment provider will discuss your specific treatment needs, however the recommended number of treatments minimum is 4. The treatment is typically about 20-30 minutes per session. Completing a full treatment series is necessary to maximize treatment efficacy and 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 strongly recommended. On the day of the treatment, you are advised to wear comfortable clothing (active wear is preferred), allowing flexibility for correct positioning during the treatment. You will be asked to remove all metallic accessories and electronic devices. 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 My electronic signature below indicates that the above information is accurate and current * Write your full name First Name Last Name Thank you!
