07516 793878

TOA CLINIC

Multi Award Winning Clinic
LONDON 2019 - 2020 2021 - 2022

Tesla sculpt

Please fill out the following form
in order to participate in our activity.

First Name

Last Name

Date of Birth

Phone

Street Address

PLEASE CHECK ALL BOXES: You are scheduled for a series of non-invasive treatments with theTsculpt. The device is indicated for improvement of abdominal tone and strengthening of the abdominal muscles same as for strengthening, toning and firming of buttocks.AND.

Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 4. The treatment is typically about 30 minutes per session, with sessions separated by at least 2 days, depending  on your needs. Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments depending on your condition.

Prior to the treatment you are not required to do anything special. 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 jewelry and electronic devices.

I acknowledge that 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.

There is typically no pain associated with your treatment and there is no anaesthetic required.  During the application you will feel intense, yet not painful 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.

Please answer whether you currently have or have had any of the following: metal or electronic implants

YES

cardiac pacemakers, implanted defibrillators, implanted neurostimulators

YES

drug pumps

YES

pulmonary insufficiency

YES

malignant tumor

YES

Fever

YES

sensitivity or allergy to latex

YES

haemorrhagic conditions

YES

anticoagulation therapy

YES

heart disorders

YES

epilepsy

YES

recent surgical procedures (muscle contraction may disrupt the healing)

YES

areas of the skin which lack normal sensation

YES

Have you been pregnant

C Section

Vaginal Birth

Are you satisfied with the strength of your core muscles?

YES

Are you satisfied with the shape of your buttocks?

YES

I am aware that the treatment cannot be applied over the head and heart

I understand that there are certain risks associated with sculpt treatments and they include  but are not limited to: muscular pain, temporary muscle spasm, temporary joint or tendon pain and 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 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 or marketing purposes.

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 Emsculpt by the physician(s) in this practice and his/her designated staff.

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

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Multi Award Winning Clinic LONDON 2019 - 2020 2021 - 2022

Tesla sculpt

Multi Award Winning Clinic
LONDON 2019 - 2020 2021 - 2022