HiFEM Body Sculpting Consent & Medical Screening FormΔPlease complete this form accurately. The information helps us determine whether treatment is appropriate and how it can be performed safely.Full Name Age Phone Number Email Emergency contact Relationship/phone: 1. About HiFEM Body Sculpting HiFEM (High-Intensity Focused Electromagnetic) body sculpting uses electromagnetic energy to stimulate repeated muscle contractions in the selected body area. The treatment is intended to support muscle conditioning and body contouring. Results vary between clients and are not guaranteed. HiFEM is not a weight-loss treatment and does not replace medical care, exercise, or a balanced diet.2. Absolute Contraindications - Treatment Must Not Be Performed Check YES or NO for each item. Any YES answer in this section means HiFEM treatment cannot be provided unless the manufacturer or an appropriately qualified medical professional confirms otherwise in writing.Pregnant or suspected to be pregnant Yes No Pacemaker Yes NoImplantable cardioverter-defibrillator (ICD) Yes No Neurostimulator Yes No Any other implanted electronic device Insulin pump, pain pump, or similar implanted pump/device Yes No Metal implant in the treatment area Yes No Metal plate in or near the treatment area Yes NoMetal screws in or near the treatment area Yes No Artificial joint in or near the treatment area Yes NoMetal mesh in or near the treatment area Yes No Malignant tumour or active cancer Yes No Muscle injury, tear, or acute inflammation in the treatment area Yes NoFever or acute infection Yes NoSevere pulmonary insufficiency Yes NoRequested treatment involves the head or heart/chest area Yes No3. Conditions Requiring a Doctor's Evaluation and Written Clearance A YES answer does not automatically exclude treatment, but treatment must be postponed until written medical clearance is provided and accepted by NB MedSpa.Breastfeeding Yes No Epilepsy or seizure disorder Yes NoPoorly controlled high blood pressure Yes NoArrhythmia or irregular heartbeat Yes NoCardiovascular disease Yes No Diabetes, especially if poorly controlled Yes No Hernia, including inguinal or umbilical hernia Yes NoDeep vein thrombosis (DVT) or a history of DVT Yes NoPhlebitis Yes No Severe varicose veins in or near the treatment area Yes NoRecent surgery (typically within the past 3-6 months) Yes NoAutoimmune disease Yes No Severe kidney disease Yes No Coagulation/bleeding disorder Yes NoCurrently taking anticoagulant or blood-thinning medication Yes No Open wound, infection, eczema, dermatitis, or burn in the treatment area Yes No4. Treatment Area and Health InformationRequested treatment area(s): Current medications and supplements: Relevant medical conditions, surgeries, or implants not listed above: Name of physician providing clearance, if applicable: Date written clearance received: 5. Possible Sensations, Side Effects, and Risks During treatment, I may feel strong or intense muscle contractions, tapping, pulling, pressure, or temporary discomfort. After treatment, temporary muscle soreness, fatigue, tenderness, cramping, redness, swelling, tingling, or sensitivity may occur. Less common risks may include bruising, muscle strain, aggravation of an undisclosed condition, or discomfort lasting longer than expected. I understand that I must immediately report unusual pain, dizziness, shortness of breath, chest discomfort, numbness, weakness, or any other concerning symptom. Treatment may be stopped at any time for safety. i understand Yes, Understand 6. Client Consent and Acknowledgmentmedical condition I confirm that I have disclosed all relevant medical conditions, medications, surgeries, implants, and changes in my health. accurate information I understand that withholding or providing inaccurate information may increase the risk of injury or complications. expected benefits I understand the nature, purpose, expected benefits, limitations, possible side effects, and risks of HiFEM treatment. guaranteed I understand that individual response varies and that no specific result has been promised or guaranteed. Pre-treatment I agree to follow all pre-treatment and aftercare instructions provided by NB MedSpa. discontinue treatment I understand that NB MedSpa may postpone, refuse, or discontinue treatment when safety concerns exist or medical clearance is required. questions I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. voluntarily I voluntarily consent to receive HiFEM body sculpting treatment.declare I declare that all information provided by me in this form is accurate and complete. Any omission, concealment, or incorrect information is solely my responsibility, and I release Zia Cosmetic Clinic and its staff from any liability arising from such inaccuracies.Submit Form
