Emsella & Emsculpt Therapy Intake Form

Please ensure you complete this form prior to your appointment with Core to Floor Rejuvenation to confirm your treatment eligibility.

Our staff are trained operators of the Emsella and Emsculpt devices but are not medical doctors. This form is for the sole purpose of screening for device contraindications and documenting your informed consent. We do not provide medical advice or diagnosis.

Our Privacy Policy is consistent with Australian privacy and data laws. You can request to erase your data or for a copy of your data at any time. Refer to the privacy policy on our website for further details.

First name

Last name

Date of birth

Email address

Phone number

Client Intake Form