Electro-Equiscope Therapy Consent Form

Electro-Equiscope Therapy Consent Form

Patient & Provider Information

Introduction / Purpose

Electro-Equiscope Therapy is a non-invasive, biofeedback-driven therapy designed to support neurological, musculoskeletal, and metabolic health. Using fingertip-controlled probes and plates, it delivers targeted electrical signals to optimize cellular function, reduce pain, and accelerate recovery.

Intended benefits may include:

  • Pain relief and reduced inflammation

  • Enhanced muscle recovery and performance

  • Improved circulation and tissue health

  • Support for nervous system and metabolic balance

Treatment Overview / How It Works

  • Small plates and probes are placed on the skin’s surface using a conductive electrolyte

  • The device scans the body and dynamically adjusts output via biofeedback in milliseconds

  • Therapy sessions are typically 20–40 minutes, depending on the treatment area and goals

  • Treatment frequency is determined by provider based on condition and response

Contraindications & Warnings

Do not use Electro-Equiscope Therapy if you have:

  • Pacemaker or implanted electronic devices

  • Pregnancy

  • Active malignancy or untreated tumors

  • Epilepsy or seizure disorders

Caution is advised for patients with:

  • Cardiovascular disease

  • Severe neuropathy or sensory deficits

  • Skin conditions at treatment sites

Possible Risks / Side Effects

  • Mild tingling, warmth, or temporary muscle twitching

  • Minor redness at electrode placement sites

  • Rare: dizziness or lightheadedness

  • Symptoms are generally transient and resolve shortly after treatment

Pre-Treatment Instructions

  • Wear comfortable, loose clothing

  • Avoid lotions, oils, or heavy moisturizers at treatment sites

  • Inform provider of any medical conditions, medications, or implants

During Treatment / Application

  • Patient remains seated or lying comfortably while electrodes and plates are applied

  • Provider monitors response and adjusts device output accordingly

  • Patient should report any discomfort or unusual sensations immediately

Post-Treatment / Aftercare

  • Mild muscle soreness or tingling may occur

  • Hydrate and rest as recommended by the provider

  • Follow up with provider if any unusual symptoms persist

Patient Responsibilities

  • Follow provider instructions before, during, and after therapy

  • Report any discomfort, pain, or adverse reactions promptly

  • Attend scheduled sessions to ensure optimal results

Acknowledgment & Consent

I acknowledge that:

  • I have read and understood this consent form

  • I understand the benefits, risks, and alternatives of Electro-Equiscope Therapy

  • I consent to treatment and accept responsibility for my own safety

  • I release AI Wellness Center of Excellence, its staff, and affiliates from any liability except in cases of gross negligence or willful misconduct

I consent to photos or video for educational or promotional purposes, if applicable