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


I understand that there are certain risks associated with EMShape® treatments. 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 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. 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 consent to be treated with the EMShape® by the service provider in Pure Sculpting, LLC and designated staff.


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