Consent For QSculpting Pro

Name *

First

Last

Contact number *

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NRIC Number (Last 4 Digits)

I understand & agree to the following

Qsculpting Pro uses Electro Magnetic Wave to induce muscle contraction to build muscle and result in fat loss . It is a non-invasive treatments with the Emsculpting Pro . The device is indicated for improvement of ,muscle toning, strengthening of the muscles, development of firmer abdomen , Arms , Thigh and Buttocks.
Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 4. The treatment is typically 30 minutes per session, with sessions separated by at least two 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 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 electronics devices.
I acknowledge that 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
I acknowledge that the treatment should preferably be applied directly over the skin. If not, I am aware not to wear any metallic accessories (such as jewelry, watch or clothes containing metallic threads) during the treatment. I also acknowledge that I do not have metallic or electronic implants (such as pacemakers, defibrillators, metallic IUDs, etc.)

Metal or electronic implants:

Yes
No

Cardiac pacemakers, implanted defibrillators, implanted neurostimulators:

Yes
No

Drug pumps:

Yes
No

Pulmonary insufficiency:

Yes
No

Malignant tumor:

Yes
No

Fever:

Yes
No

Metallic IUD:

Yes
No

Hemorrhagic conditions:

Yes
No

Injured or otherwise impaired muscles:

Yes
No

Heart disorders:

Yes
No

Epilepsy:

Yes
No

Recent surgical procedures (muscle contraction may disrupt healing):

Yes
No

If you answer YES to any of these questions above , YOU ARE NOT A SUITABLE CANDIDATE FOR THIS TREATMENT

Treatment considerations

I am aware that the treatment cannot be applied over the head, heart and neck.
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 Qsculpting Pro 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 decreases.
I understand that the treatment over injured or otherwise impaored 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 result of the treatment. Information will be acquired for medical records or marketing purposes.
I understand the results may vary from person to person and that anexact result cannot be predicated. 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 results 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 Qsculpting by the practitioner in this practice and her designated staff.

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