Client Name *

Date of Birth *

Phone Number *

Email Address *

Treatment Date *

Practitioner / Witness Name *

Consent Version

Consent Version: ELURENA-CONSENT-EMS-V1.0-2026

Section Title

ELURENA – EMS TREATMENT CONSENT & LIABILITY FORM

About the Treatment

Elurena EMS (Electro Muscle Stimulation) uses gentle electrical impulses to contract muscles and improve tone, strength, and circulation. This is a non-invasive treatment. Results vary per person.

What to Expect

During or after EMS treatment, you may experience:

Tingling, warmth, or muscle contractions during treatment.Temporary redness, muscle fatigue, or soreness similar to exercise.Rare risks may include skin irritation, bruising, dizziness, or over-stimulation of muscles.Results are gradual and may require multiple sessions.No refunds are offered for treatments.

Do you have a pacemaker or implanted electronic device? *

Yes No

Do you have heart disease or an irregular heartbeat? *

Yes No

Do you have epilepsy or a history of seizures? *

Yes No

Do you have metal implants in the treatment area? *

Yes No

Are you pregnant or breastfeeding? *

Yes No

Do you have open wounds, infections, or skin conditions in the treatment area? *

Yes No

Do you have cancer or any serious medical condition? *

Yes No

Have you had recent surgery or injury in the treatment area? *

Yes No

Do you have bleeding disorders or use blood thinners? *

Yes No

Have you disclosed your full and accurate medical history to the practitioner? *

Yes No

Are you currently taking any medication that may affect treatment safety? *

Yes No

Have you had any recent cosmetic, medical, or aesthetic procedures in the treatment area? *

Yes No

Do you understand that treatment may be refused or postponed if there is a safety concern? *

Yes No

EMS Consent Confirmation *

I understand the EMS treatment, possible risks, contraindications, and limitations. I understand that results are not guaranteed and that multiple sessions may be required. I confirm that I have disclosed my full medical history and give consent to proceed with EMS treatment.

Optional Photography Consent

I authorize Elurena and its staff to take photographs of me for documenting treatment progress and results, training, education, and marketing use. I understand my name will not be used, my face will not be shown unless I give specific permission, and I may revoke this consent in writing at any time.

Photography Progress Consent

I consent to photographs being taken for treatment progress documentation only.

Photography Training Consent

I consent to photographs being used for training and education.

Photography Marketing Consent

I consent to photographs being used for marketing, digital, print, or online purposes.

Photography Face Consent

I specifically consent to my face being shown, if required.

Treatment Information Confirmation *

I confirm that I have read and understood the EMS treatment information shown in this form.

Risks and Limitations Confirmation *

I confirm that I understand the possible risks, side effects, contraindications, and limitations of EMS treatment.

No Guaranteed Results Confirmation *

I understand that treatment results vary and are not guaranteed.

Multiple Sessions Confirmation *

I understand that more than one session may be required.

No Refunds Confirmation *

I understand that no refunds are offered for completed treatments.

Questions Confirmation *

I confirm that I have had the opportunity to ask questions before proceeding.

Consent to Proceed *

I consent to proceed with EMS treatment.

Client Signature *

Client Signature Date *

Practitioner / Witness Signature *

Practitioner / Witness Signature Date *

ELURENA – EMS Treatment Consent

ELURENA – EMS TREATMENT CONSENT & LIABILITY FORM