EMS Therapy Consent Form

EMS Therapy Consent Form

Patient & Provider Information

Introduction / Purpose

EMS (Electro Musculoskeletal Stimulation) Therapy uses controlled electrical impulses to stimulate muscles for:

  • Enhancing muscle strength and endurance

  • Promoting recovery from injury or fatigue

  • Improving blood flow and circulation

  • Supporting rehabilitation and overall physical performance

Treatment Overview / How It Works

  • EMS devices send electrical impulses to target muscles via surface electrodes

  • Sessions typically last 15–45 minutes, depending on treatment goals

  • Intensity, frequency, and duration are customized per patient needs

  • Multiple sessions per week may be recommended for optimal results

Contraindications & Warnings

EMS Therapy may not be suitable for patients with:

  • Pacemakers, defibrillators, or implanted electronic devices

  • Pregnancy or breastfeeding without medical clearance

  • Active cancer or malignant tumors in the treatment area

  • Severe cardiovascular conditions without provider approval

  • Skin infections, open wounds, or recent surgery at the target site

Precautions:

  • Remove all metallic objects from treatment area

  • Inform provider of any implants, medical devices, or health conditions

  • Avoid EMS over areas with reduced sensation or nerve damage

Possible Risks / Side Effects

  • Mild: Tingling, muscle twitching, or temporary soreness

  • Rare: Skin irritation or minor bruising at electrode placement

  • Very rare: Overstimulation causing temporary muscle fatigue or discomfort

Pre-Treatment Instructions

  • Wear comfortable clothing exposing the target muscle groups

  • Avoid lotions, oils, or creams on the skin in treatment areas

  • Stay hydrated and inform provider of any recent injuries, surgeries, or medical changes

During Treatment

  • Electrodes will be applied to targeted muscle groups

  • Patients may feel rhythmic contractions; intensity will be adjusted for comfort

  • Provider will monitor patient response and adjust parameters as needed

Post-Treatment / Aftercare

  • Mild muscle soreness is normal and usually resolves within 24–48 hours

  • Drink water to support recovery

  • Resume normal activities unless otherwise instructed

  • Contact provider for persistent pain, discomfort, or unusual reactions

Patient Responsibilities

  • Provide accurate medical history and disclose all health conditions or devices

  • Follow pre- and post-treatment instructions

  • Report any side effects, discomfort, or concerns immediately

Acknowledgment & Consent

  • I understand the purpose, risks, benefits, and alternatives of EMS Therapy

  • I voluntarily consent to undergo treatment at AI Wellness Center of Excellence

  • I acknowledge that results may vary and no guarantees are made regarding outcomes

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

I consent to photographs, recordings, or data capture for medical documentation, education, or research if applicable