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Consent & Photo release form

Date of birth
Gender

Please answer whether you currently have or had any of the following in the past .

Electronic implants (such as cardiac pacemakers, defibrillators and neurostimulators
Yes
No
Metal implants
Yes
No
Drug pumps
Yes
No
Malignant Tumor
Yes
No
Pulmonary Insufficiency
Yes
No
Injured or otherwise impaired muscles
Yes
No
Cardiovascular diseases
Yes
No
Disturbance of temperature or pain perception
Yes
No
Septic conditions and empyema
Yes
No
Acute inflammations
Yes
No
Systemic or local infection such as osteomyelitis and tuberculosis
Yes
No
Contagious skin disease
Yes
No
Are you currently pregnant
Yes
No
Metallic IUD
Yes
No
Diastasis recti
Yes
No
Pregnancy: Vaginal, Cesarean birth
Yes
No

TREATMENT CONSIDERATIONS

You are scheduled to Demo a non-invasive treatments with the BTL EMSELLA (and/or) EMSCULPT NEO device.

BTL EMSELLA is intended to provide entirely non-invasive electromagnetic stimulation of pelvic floor musculature for

the purpose of rehabilitation of weak pelvic muscles and restoration of neuromuscular control for the treatment of

urinary incontinence

EMSCULPT NEO® is indicated for non-invasive lipolysis (breakdown of fat) of the abdomen and thighs and

reduction in circumference of the abdomen and thighs with Skin Type I to Skin Type VI; and for non-invasive lipolysis

(breakdown of fat) of the upper arms limited to skin types II and III and BMI 30 or under. EMSCULPT NEO® is also

indicated for improvement of abdominal tone, strengthening of the abdominal muscles, development of firmer

abdomen; strengthening, toning, and firming of buttocks, thighs, and calves; and improvement of muscle tone and

firmness, for strengthening muscles in arms.

There is typically no pain associated with your treatment and there is no anesthetic required. You will experience

gradually increasing tingling feeling and muscle contractions. These sensations in the pelvic area are normal and

expected. You remain fully clothed during the treatment.

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

heating sensation in the treated area. It is important to note that during the treatment the heating sensation may be

intense, but it should never be painful. Please ask your provider to re-adjust the intensity should you feel any pain or

discomfort. The procedure doesn’t require any recovery time. Typically, you can get back to your daily routine right

after the treatment.

I understand that there are certain side effects associated with EMSCULPT NEO treatments. The side effects 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.

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

heating sensation in the treated area. It is important to note that during the treatment the heating sensation may

be intense, but it should never be painful. Please ask your provider to re-adjust the intensity should you feel any

pain or discomfort. The procedure doesn’t require any recovery time. Typically, you can get back to your daily

routine right after the treatment.

I am aware that pregnancy is contraindicated and pregnant women can’t undergo the treatment.

I am aware that I can’t undergo the treatment when menstruating.

I am willing to fill in forms and/or anonymous questionnaires if requested, as this will help for medical evaluation of

the results of the treatment. Information will be acquired for medical records or marketing purposes.

I understand that there are certain side effects associated with EMSCULPT NEO treatments. The side effects 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 understand there are certain risks associated with BTL EMSELLA treatments and they include but are not limited

to: muscular pain, temporary muscle spasm, temporary joint or tendon pain, local erythema or skin redness. 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 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 BTL EMSELLA

(and/or) EMSCULPT NEO procedure by the physician(s) in the below stated practice and his/her designated staff.

Date

* For the full range of possible adverse effects and expected device-related treatment sequelae, consult your treatment provider.

©2023 by Team Baby Catcher

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