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info@toaclinic.co.uk

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Award Winning Clinic

Multi Award Winning Clinic
LONDON 2019 - 2020 2021 - 2022

Award Winning Clinic

Tesla sculpt

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

First Name

Last Name

Email

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

NO

cardiac pacemakers, implanted defibrillators, implanted neurostimulators

YES

NO

drug pumps

YES

NO

pulmonary insufficiency

YES

NO

malignant tumor

YES

NO

Fever

YES

NO

sensitivity or allergy to latex

YES

NO

haemorrhagic conditions

YES

NO

anticoagulation therapy

YES

NO

heart disorders

YES

NO

epilepsy

YES

NO

recent surgical procedures (muscle contraction may disrupt the healing)

YES

NO

areas of the skin which lack normal sensation

YES

NO

Have you been pregnant

C Section

Vaginal Birth

Are you satisfied with the strength of your core muscles?

YES

NO

Are you satisfied with the shape of your buttocks?

YES

NO

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.

Select a date

Thanks for submitting!

info@toaclinic.co.uk

154b Battersea Park Road Road, Battersea London

10 Harley Street WIG9PF

SW11 4ND tel: 07516793878

Company Number: 10316085

Registered Address: Kemp House, 160
City Road, London, United
Kingdom, EC1V 2NX

©2016 TOA Clinic

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