EmSculpt Neo Eligibility Form

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Want to try EmSculpt Neo? Wondering if you're a good candidate? Please answer all questions below. Responding 'yes' to any of the questions does not automatically mean you are ineligible. Upon submission of this form, a clinician at Milford Med Spa will contact you to discuss your results and advise you on how to proceed.

Milford Med Spa

E-Mail-Adresse *

First and Last Name *

What is your phone number? *

Do you have metal or electronic implants? *

Yes

Do you have any cardiac pacemakers, implanted defibrillators, or implanted neurostimulators? *

Yes

Do you have drug pumps? *

Yes

Do you have pulmonary insufficiency? *

Yes

Do you have injured or otherwise impaired muscles? *

Yes

Do you have a malignant tumor? *

Yes

Do you have any cardiovascular diseases? *

Yes

Do you have a disturbance of temperature or pain perception? *

Yes

Do you have any hemorrhagic conditions? *

Yes

Do you have septic conditions and empyema? *

Yes

Do you have acute inflammations? *

Yes

Do you have systemic or local infection such as osteomyelitis and tuberculosis? *

Yes

Do you have a contagious skin disease? *

Yes

Do you have an elevated body temperature? *

Yes

Are you currently pregnant, experiencing a postpartum period, nursing, or menstruating? *

Yes

Do you have Basedow's or Grave's disease? *

Yes

Do you have a metallic IUD? *

Yes

Have you had any recent surgical procedures? *

(muscle contraction may disrupt the healing)

Yes

Do you have any areas of the skin which lack normal sensation? *

Yes

If you answered yes to any of the questions above, please elaborate here:

What is your BMI? *

If your BMI is 35 or below, EmSculpt Neo studies show you will see 30% fat loss and 25% muscle gains on average. If your BMI is above 35, you may not see these results and and you may need more than 4 treatments for desired results.

My BMI is 35 or below

My BMI is above 35

I don't know my BMI - please provide your height and weight below

If you don't know your BMI: Here is my height and weight:

How did you hear about us? *

Instagram

Facebook

Google

Billboard

Friend/Colleague

Sonstiges:

Thank you for completing our form. Please check us out at https://milfordmedspa.com/. You will be contacted via phone call, email, or text message once your form has been reviewed by our clinician.

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