SCHEDULE YOUR FREE CONSULTATION!

Services
Facials Memberships Sculpting & Rejuvenation InBody Scan Zyto Scan Cupping Therapy Holistic & Biological Dentistry
Products
About Contact

Client Agreement & Consent Form

Informed Consent & Understanding

I confirm that:

  • I am voluntarily seeking the above services at Radical WellSpa.
  • I have reviewed information about how these treatments work and understand they may carry risks including but not limited to: redness, bruising, soreness, skin sensitivity, fatigue, dizziness, and rare complications.
  • I understand results vary and are not guaranteed.
  • I have had the opportunity to ask questions and may refuse or stop treatment at any time.

Pre-treatment Compliance

I confirm that:

  • I have followed all pre-treatment instructions (e.g., avoided alcohol, stayed hydrated, avoided sun exposure).
  • I will notify staff of recent health changes before each session.
  • I understand appointments may be rescheduled if I am unwell or deemed ineligible for safe treatment.

Aftercare Responsibility

I understand that Radical WellSpa is not a medical provider and does not offer post-treatment medical care. If I experience any unusual or concerning symptoms after my service, I agree to contact my own healthcare provider. I acknowledge that Radical WellSpa is not responsible for diagnosing or treating any reactions that may occur.

Privacy, Date & Communication Consent

I agree to the following:

  • I authorize Radical WellSpa to securely store my health and contact information.
  • I understand my information is used for treatment and internal purposes only and will not be shared without my written consent.
  • I authorize communication via email/text for appointments and wellness updates.
  • I may opt out of communications at any time.

Photo Consent & Image Use

Radical  WellSpa takes before-and-after photos as part of your confidential client file to track treatment progress.

I understand that photos will be taken for clinical documentation and securely stored in my client file.

Liability Waiver & Arbitration Agreement

I hereby release Radical WellSpa LLC, its staff, owners, contractors, and affiliates from liability for any injuries, reactions, or complications resulting from products or services.

I acknowledge that:

  •  I am responsible for disclosing accurate and complete health information.
  • I agree to resolve any disputes through confidential binding arbitration, except as prohibited by law.

Facial Terms and Agreements

I understand that the facial treatment I receive is intended to improve the appearance and health of my skin. I acknowledge that:

  • Individual results may vary.
  • Temporary redness, sensitivity, breakouts, or skin purging may occur.
  • It is my responsibility to inform the provider of any medical conditions, recent procedures, or product use.
  • Areas with permanent makeup or facial threads may be avoided or require special care during treatment.
  • Home skincare products may interact with professional treatments and affect results.
  • I must follow all pre- and post-treatment instructions provided by the practitioner.

I confirm that I have disclosed all relevant information including permanent makeup, facial threads, and skincare products used at home. I give my voluntary and informed consent to proceed with the facial treatment.

Emsculpt Terms and Agreements

I acknowledge that the following terms and agreements apply to receiving Emsculpt treatments:

You are scheduled for a series of non-invasive treatments with the EMSCULPT NEO®.

EMSCULPT NEO is indicated to be used for:

  • Improvement of abdominal tone, strengthening of the abdominal muscles, development of firmer abdomen.
  • Strengthening, Toning and Firming of buttocks, thighs, and calves.
  • Improvement of muscle tone and firmness, for strengthening muscles in arms.
  • Non-invasive lipolysis (breakdown of fat) of the abdomen.
  • Reduction in circumference of the abdomen.
  • Non-invasive lipolysis (breakdown of fat) of the thighs.
  • Reduction in circumference of the thighs.
  • EMSCULPT NEO is intended for use with skin types I – VI.
  • Non-invasive lipolysis (breakdown of fat) of the flanks limited to skin types I - IV.
  • Non-invasive lipolysis (breakdown of fat) of the upper arms limited to skin types II and III and BMI 30 and under.

The EMSCULPT NEO device is intended to be used under medical supervision for adjunctive therapy for the treatment of medical diseases and conditions.

The EMSCULPT NEO device is indicated for use in stimulating neuromuscular tissue for bulk muscle excitation in the legs or arms for rehabilitative purposes.

Indications for Use for Muscle Stimulators:

  • Relaxation of muscle spasms
  • Prevention or retardation of disuse atrophy
  • Increasing local blood circulation
  • Muscle re-education
  • Immediate post-surgical stimulation of calf muscles to prevent venous thrombosis
  • Maintaining or increasing range of motion

Your treatment provider will discuss your specific treatment needs. The recommended number of treatments is four. Each treatment typically lasts about 20 to 30 minutes per session, with sessions separated by 5 to 10 days for the HIFEM+RF Advance/Gentle/Function preset or 2 to 3 days for the HIFEM Classic/Function preset. Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments depending on your goals.

No unusual preparations are required before the treatment; however, it is strongly recommended to keep your body well-hydrated. On the day of the treatment, it’s advisable to wear comfortable clothing that allows flexibility for proper positioning during the procedure. To prevent excessive sweating, the treatment area should be shaved or the hair trimmed beforehand. The treated area will also be wiped with alcohol wipes before the treatment to remove any moisture, perfume, moisturizers, or oils. You will be asked to remove all metallic accessories and electronic devices.

I acknowledge that smoking, excessive alcohol consumption, eating disorders, and certain medications may affect the success of the treatment outcome. While no special diet is required, maintaining a healthy diet is encouraged to help promote and sustain results.

The treatment does not require anesthesia. During the procedure, you may feel intense muscle contractions and a warming sensation in the treated area. It’s important to note that while the warming sensation may be intense, it should never be painful. If you experience any pain or discomfort, please ask your provider to adjust the intensity. The procedure requires no recovery time, and you can typically return to your daily routine immediately afterward.

I am aware that I MUST NOT wear any metallic accessories (such as jewelry, watches, or clothing with metallic threads or accessories) during the treatment. I also confirm that I do not have any metallic or electronic implants (such as pacemakers, defibrillators, metallic IUDs, etc.).

Treatment Considerations

I agree to the following:

  • I am aware that the treatment cannot be applied over the head, neck, spinal cord, heart, or testes.
  • I am aware that the treatment cannot be applied over swollen or neoplastic tissues, space-occupying lesions, or skin eruptions.
  • I am aware that pregnancy is contraindication, and pregnant women cannot undergo the treatment.
  • I am aware that with any heat-based therapy, in rare cases, burns can occur.
  • I am aware that the applicators must always be in direct contact with the skin. I am aware that treatment must not be applied over clothing or scar tissue.
  • I understand that there are certain side effects associated with EMSCULPT NEO treatments. The side effects may include, but are not limited to muscular pain, intramuscular fat decrease, temporary muscle spasm, temporary joint or tendon pain, local erythema or skin redness, increased menstrual flow in female patients and panniculitis.
  • I understand that the treatment over muscles in the acute phase of injury is contraindicated.
  • 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 aid in the medical evaluation of the results of the treatment. This information will be collected for medical records or marketing purposes.
  • I understand 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 I acknowledge that it is possible not to experience any noticeable results after the procedure. I understand that the results may not meet my expectations.
  • I certify that I have read this entire document and 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 NEO by the physician(s) at this practice and their designated staff.

Emsella Terms and Agreements

I acknowledge that the following terms and agreements apply to receiving Emsella treatments:

Treatment Considerations

You are scheduled for a series of non-invasive treatments with the BTL EMSELLA device.

BTL EMSELLA is intended to provide entirely non-invasive electromagnetic stimulation of pelvic floor musculature for the purpose of rehabilitation of weak pelvic muscles and restoration of neuromuscular control for the treatment of male and female urinary incontinence.

Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 6. 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 the severity of your condition. The results will typically continue to improve over the next few weeks.

There is typically no pain associated with your treatment and there is no anesthetic required. You will experience gradually increasing tingling feeling and muscle contractions. These sensations in the pelvic area are normal and expected. You remain fully clothed during the treatment.

On the day of the treatment, you are advised to wear comfortable clothes which allow flexibility for correct positioning and increased comfort during the treatment.

For the full range of contraindications, warnings and cautions, consult your treatment provider.

  • I am aware that pregnancy is contraindicated and pregnant women can’t undergo the treatment.
  • I am aware that I can’t undergo the treatment when menstruating.
  • I understand there are certain risks associated with BTL EMSELLA treatments and they include but are not limited to: muscular pain, temporary muscle spasm, temporary joint or tendon pain, 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 am willing to fill in forms and/or anonymous questionnaires if requested, 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. 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 BTL EMSELLA procedure by the physician(s) in the below stated practice and his/her designated staff.

Emface Terms and Agreements

I acknowledge that the following terms and agreements apply if to receiving Emface treatments:

You are scheduled for a series of non-invasive treatments with the EMFACE®. The EMFACE device, used with the EMFACE Forehead and EMFACE Cheek applicators, is intended to provide:

  • Heating for the purpose of elevating tissue temperature for selected medical conditions, such as temporary relief of pain, muscle spasms, and an increase in local circulation. 
  • Non-invasive temporary reduction of facial wrinkles.

The EMFACE device used with EMFACE Forehead, EMFACE Eye,  EMFACE Cheek, and EMFACE Submentum applicators is indicated for:

  • Aesthetic use, including facial and neck stimulation or body skin stimulation.

The EMFACE Submentum applicator is further cleared to affect the appearance of lax tissue in the submental area.

Your treatment provider will discuss your specific treatment needs. Four sessions are recommended, with 2–14 days between each session. The typical session length is about 20 minutes. Completing a full treatment series is necessary to maximize efficacy. You may require additional sessions depending on the severity of your condition.

The area of interest should be free from hair. I acknowledge that I have been advised to shave this area prior to the procedure, or that it will be shaved at the time of the procedure visit.

On the day of the treatment, you are advised to wear comfortable clothing to allow easy access for placement of the neutral electrode. Additionally, the facial treatment area will be wiped with a cleanser before treatment to remove any moisture, perfume, moisturizers, or oils. You will also be asked to remove all metallic accessories and electronic devices.

The treatment does not require anesthesia. During the application, you will feel muscle contractions and a heating sensation in the treated area. It is important to note that you should feel comfortable heat, but never feel an unpleasant burning or pain sensation during the treatment. Please ask your provider to re-adjust the intensity should you feel any pain or discomfort. The procedure doesn’t require any recovery time. Typically, you can get back to your daily routine right after the treatment.

I am aware that the treatment should not be uncomfortable or painful. I have been advised to press the Therapy discomfort button if I feel any pain or discomfort during therapy.

I am aware NOT TO wear any metallic accessories (such as jewelry, watches, or clothes containing metallic threads or  components) during the treatment. I also acknowledge that I do not have any metallic or electronic implants near the treatment area (such as pacemakers, defibrillators, etc.).

Treatment Considerations

  • I am aware that pregnancy and nursing are contraindications, and that pregnant women should not undergo the treatment.

  • I am aware that, as with any heat-based therapy, damage to natural skin texture (such as crusting, blistering, or burning) can occur in rare cases.

  • I understand that there are certain side effects associated with EMFACE treatments. Possible side effects include, but are not limited to, erythema, mild swelling, a heating sensation, dry skin, temporary damage to natural skin texture (such as crusting, blistering, or burning), muscular pain, temporary muscle spasms, and increased tear secretion during or immediately after the procedure.

  • 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 understand that results may vary from person to person and that an exact outcome cannot be predicted. Completing a full treatment series is recommended to achieve optimal results. Although unlikely, I acknowledge that I may not experience noticeable results after the procedure. Additionally, I recognize that the results may not meet my personal expectations.

  • I certify that I have read this entire document and agree with all its provisions. I confirm that I have had the opportunity to ask questions, and that all my questions have been answered to my full satisfaction. I fully understand the treatment conditions, the procedure, and possible side effects.

  • I have read the above information and hereby give my consent to be treated with EMFACE by the physician(s) in this practice and their designated staff.

Exion Terms and Agreements

I acknowledge that the following terms and agreements apply if to receiving Exion treatments:

EXION FRACTIONAL RF APPLICATOR

You are scheduled for a series of minimally invasive EXION Fractional RF or EXION Clear RF treatments using the EXION Fractional RF Applicator. The EXION Fractional RF applicator used with the Non-insulated and Insulated single-use tips is intended for use in dermatological and general surgical procedures for electrocoagulation and hemostasis. The EXION Fractional RF applicator used with Clear RF tip is intended for dermatological procedures requiring fractional treatment of the skin.

A recommended course of treatment typically involves 2 to 5 sessions, with a one- to six-week interval between each session, depending on the individual's healing process.

The area of interest must be free from hair, makeup, creams, and lotions. I acknowledge that I have been advised to shave the area prior to the procedure, or the area will be shaved at the procedure visit.

On the day of the treatment, you are advised to wear comfortable clothing so the treatment area can be easily accessed. Also, the treated area will be wiped with a cleanser before treatment to remove any moisture, perfume, moisturizers, or oils. You will also be asked to remove all metallic accessories and electronic devices.

The treatment may be associated with some level of discomfort. A topical anesthetic in the form of numbing cream may be used when needed. Following the Fractional RF treatment, it is common for patients to experience varying degrees of erythema (redness) and edema (swelling). Visibility of small crusts, blisters or burns occasionally develop at contact locations. These typically slough within one week for sensitive skin.

I am aware NOT TO wear any metallic accessories (such as jewelry, watches or clothes containing metallic threads or metallic accessories) during the treatment. I also acknowledge that I do not have any metallic or electronic implants near the treatment area (such as pacemakers, defibrillators, etc.).

Following the treatment, it is recommended to avoid sun exposure or any excessive tanning for several days after the treatment. A broad-spectrum UVA/UVB sunblock should be used outdoors until the skin is completely healed. Patients should also avoid skin irritation in the treated area for 24-48 hours after therapy and may apply makeup only 24-72 hours after each session if the skin is not broken. While regular soaps are fine, scrub soaps or exfoliants should be generally avoided for 24 hours after treatment.

Treatment Considerations

  • I am aware that pregnancy and nursing are contraindications, and pregnant women cannot undergo the treatment.
  • I understand that there are certain side effects associated with EXION Fractional RF applicator treatments. These side effects may include, but are not limited to, an intense heating sensation, pain, bleeding at contact locations, erythema, edema, itching and irritation, discomfort/sensitivity to firm tissue palpation, pigmentation change including hypopigmentation, hyperpigmentation, and post-inflammatory hyperpigmentation, temporary visibility of small crusts, blisters or burns.
  • I understand that the results may vary from person to person and that an exact result cannot be predicted. It is very unlikely, but it is possible that I will not see any recognizable results after the procedure. Completing a full treatment series is recommended to maximize treatment efficacy. I acknowledge that the results may not meet my expectations.
  • I certify that I have read this entire document and I agree with all provisions. I also 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 EXION Fractional RF or Clear RF by the physician(s) at the practice named below and his/her designated staff.

EXION FACE APPLICATOR

You are scheduled for a series of non-invasive treatments with the EXION Face Applicator. The EXION Face applicator is intended to provide heating for the purpose of elevating tissue temperature for selected medical conditions such as temporary relief of pain, muscle spasms, and increase in local circulation.

Your treatment provider will discuss your specific treatment needs. Four sessions are recommended with 2-14 days between each session. Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments depending on the severity of your condition.

The area of interest must be free from hair. I acknowledge that I have been advised to shave the area prior to the procedure, or the area will be shaved at the procedure visit.

On the day of the treatment, you are advised to wear comfortable clothing so the treatment area can be easily accessed. Also, the treated area will be wiped with a cleanser before treatment to remove any moisture, perfume, moisturizers, or oils. You will be asked to remove all metallic accessories and electronic devices.

The treatment does not require anesthesia. During the application, you will feel a heating sensation in the treated area. It is important to note that you should feel comfortable heat, but never feel an unpleasant burning or painful sensation during the treatment. If you feel uncomfortable, immediately inform the operator. The procedure doesn’t require any recovery time. Typically, you can get back to your daily routine right after the treatment.

I am aware NOT TO wear any metallic accessories (such as jewelry, watch or clothes containing metallic threads or metallic accessories) during the treatment. I also acknowledge that I do not have any metallic or electronic implants near the treatment area (such as pacemakers, defibrillators, etc.).

Treatment Considerations

  • I am aware that pregnancy and nursing are contraindicated, and pregnant women can’t undergo the treatment.
  • I understand that there are certain side effects associated with EXION Face Applicator treatments, and they include but are not limited to erythema, mild swelling, heating sensation, dry skin, temporary damage to natural skin texture (crust, blister, and burn).
  • I understand the results may vary from person to person and that an exact result cannot be predicted. It is very unlikely, but it is possible that I will not see any recognizable result after the procedure. Completing a full treatment series is recommended to maximize treatment efficacy. 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 EXION Face Applicator by the physician(s) in the below-stated practice and his/her designated staff.

Client's Electronic Signature

By checking the box on the online scheduler's form that states "I agree to the terms and conditions of the Client Agreement & Consent Form," I confirm that:

  • All information in the online form that I've provided is complete and accurate.
  • I have read, understand, and agree to the terms of this from including the treatments I elect to receive (e.g., Emsculpt Neo,  Emsella, Exion, Emface, etc.).
  • I voluntarily choose to receive the services of Radical WellSpa LLC.

Radical WellSpa LLC | 3326 Aspen Grove Dr, Suite 110 | Franklin, TN 37067 | 615-861-9773 | [email protected]