FSM Consent Form - Acuity Massage and Advanced Skin Care

Frequency Specific Microcurrent Consent Form

I,*
First Last
Authorize Acuity Massage & Advanced Skin Care, LLC to perform the treatment known as Frequency Specific Microcurrent therapy (FSM). This is a non-invasive means of treating various conditions including pain and inflammation. The equipment that we use is classified by the FDA as TENS unit/device. To date there are no complications, short or long term, with the device. I understand that FSM involves the use of physiologic (tiny) amounts of electric current (millionths of an ampere) applied to the body. In comparison, a TENS unit produces milliamps, which are 1000 times greater. I understand that there is no implied or stated guarantee of improvement or effectiveness of a specific treatment(s). Every person is different. However, I recognize that potential for improvement by following the directives of my therapist. There are some people who may not be able to receive FSM therapy, including women who are pregnant and clients with pacemakers, blood clots, seizures, cancer, and active infection, or a spinal stimulator.
Please read and initial the following statements below.
I am not pregnant, do not have any serious health conditions or implants such as heart problems, cancer, a pacemaker, or any electrical device or stimulator, seizures or epilepsy, blood clots, or phlebitis. I do not have any infections, do not have COVID-19 or been around someone with COVID-19 symptoms or confirmed with the infection, within the last two weeks. I have not traveled or been around anyone that has traveled within the last two weeks. Please initial and note below if you have any of the above.
Initial*
Note below if you have any of the above
Please be sure to make your therapist aware of any recent injuries or surgery, even if they are minor, as this may change your treatment protocol.
Initial*
Note below if applicable
Potential Risks: FMS has a history of safety and side effects are uncommon. If they do arise, they can typically start during or about 90 minutes after treatment and last for a few minutes to a few hours. Side effects are similar to any use of stimulation to the body, including Ultrasounds, EKG, or even having a massage. These can include irritation at the site (if applied directly to the skin), soreness, fatigue, light-headedness, dizziness, drowsiness, flu-like symptoms, or transient weakness. The FSM can help clear long stored waste and metabolic products in the body.

These side effects can be greatly avoided by being very hydrated and it is recommended that you drink at least two quarts of water up to two hours before treatment and remain hydrated post treatment. If you are older, please hydrate for 5-7 days.

FSM does NOT WORK if you are dehydrated. Picture a piece of fresh meat compared to that has been dehydrated. Which would be the most pliable and easier to manipulate and change?

Potential Benefits: Microcurrent therapy is painless, often speeds the rate of recovery, and promotes healing in conditions that have not responded to other treatments. Microcurrent therapy can also lead to resolution of a health concern being treated. Often a client feels calmer and greater sense of well-being after treatment. Positive effects are long lasting and occur without pharmaceutical drugs.
Like all procedures and treatments, I recognize that FSM therapy has potential risks and potential benefits.
Initial below that you understand the risks and benefits listed.*
I hereby release Acuity Massage & Advanced Skin Care from liability in connection to the FSM therapy I receive. I understand that I can discontinue treatment at any time.
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Frequency Specific Microcurrent Consent Form

Please read and initial the following statements below.

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