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Informed Consent

EMSCULPT TREATMENT 

ACKNOWLEDGMENT, WAIVER, AND CONSENT TO RECEIVE THE LASER TATTOO REMOVAL PROCEDURE. DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS CONTENTS. 


1. Emsculpt Procedure

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



2.  What to expect:

Your treatment provider will discuss your specific treatment needs. Recommended the minimum number of treatments is 4. The treatment is typically about 20-30 minutes per session, with sessions separated by at least two to three 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 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 metallic accessories and electronic devices.

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.


 3. Treatment considerations:

I hereby authorize Bared Monkey MedSpa Inc. and all its affiliated companies and the trained, licensed staffs in this practice to perform the Emsculpt procedure on me. I understand that I will require several treatments to obtain an optimum result and the outcome may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment.


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


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 tendon pain, local erythema or skin redness and intramuscular fat decrease.

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 understand that the treatment over injured or otherwise impaired muscles is contraindicated


I agree to before and after treatment photographs, measurements and weighing, as this will help for medical evaluation of the results of the treatment. 


 

I certify that I have read and understood all information presented to me, and I have been given an opportunity to ask questions before signing this consent. I acknowledge and accept the risks inherent in the Emsculpt procedure. I voluntarily assume the risk of possible complications and side effects which may arise from the Emsculpt treatment set forth herein; and any of my heirs, executors, representatives or assigns hereby release Bared Monkey MedSpa Inc. and all its affiliated companies from any and all claims, liabilities for personal injury, and property damages of any kind sustained while on the premises, during the treatments set forth herein by any employees or representatives of Bared Monkey MedSpa Inc. and all its affiliated companies. 

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

April 27, 2024

 




First Patient's Name

First Name*

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Signature*
Second Patient's Name

First Name*

Last Name*
Second Patient's Date of Birth*
Third Patient's Name

First Name*

Last Name*
Third Patient's Date of Birth*
Fourth Patient's Name

First Name*

Last Name*
Fourth Patient's Date of Birth*
Fifth Patient's Name

First Name*

Last Name*
Fifth Patient's Date of Birth*
Sixth Patient's Name

First Name*

Last Name*
Sixth Patient's Date of Birth*
Seventh Patient's Name

First Name*

Last Name*
Seventh Patient's Date of Birth*
Eighth Patient's Name

First Name*

Last Name*
Eighth Patient's Date of Birth*
Ninth Patient's Name

First Name*

Last Name*
Ninth Patient's Date of Birth*
Tenth Patient's Name

First Name*

Last Name*
Tenth Patient's Date of Birth*
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Ethnicity
Please specify your genetic origin:
African American
Asian
Caucasian
Hispanic
Mediterranean
Middle Eastern
Native American
Other
Females Only
Are you pregnant?*
No
Yes
N/A
Are you planning pregnancy during the course of your treatments?*
No
Yes
N/A
Medical and Surgical History
Please answer whether you currently have or have had any of the following by marking off which apply to you:
Metal or electronic implants
Pulmonary insufficiency
Metallic IUD
Injured or otherwise impaired muscles
Recent surgical procedures (muscle contraction may disrupt the healing)
Cardiac pacemakers, implanted defibrillators, implanted neurostimulators
Malignant tumor
Ongoing pregnancy
Heart disorders
Areas of the skin which lack normal sensation
Drug pumps
Hemorrhagic conditions
Epilepsy

If you marked off any of the above, please specify:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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