This is a sample of the form that all new clients will be required to read and sign prior to their first treatment.

MARIN SHOCKWAVE

Acoustic Wave Therapy Services

INFORMED CONSENT TO TREATMENT

Extracorporeal Shockwave Therapy (ESWT) | Electromagnetic Transduction Therapy (EMTT) | Extracorporeal Pulse Activation Technology (EPAT)

Client Information

Client Name: _____________________________________________     Date: ____________________

Date of Birth: ______________________________     Phone: ______________________________

Area(s) to be Treated: ___________________________________________________________________________

1.  Description of Services

Marin Shockwave provides non-invasive acoustic wave therapy sessions utilizing the following technologies:

Extracorporeal Shockwave Therapy (ESWT): High-energy acoustic waves delivered to targeted tissues to stimulate cellular repair, reduce pain, and promote healing responses.

Electromagnetic Transduction Therapy (EMTT): High-frequency electromagnetic pulses used to support tissue regeneration, reduce inflammation, and address musculoskeletal discomfort.

Extracorporeal Pulse Activation Technology (EPAT): Pressure waves applied to soft tissue to enhance circulation, accelerate metabolic activity, and reduce musculoskeletal symptoms.

2.  Scope of Practice — Important Limitations

I understand and acknowledge the following regarding the scope of services provided by Marin Shockwave:

■  Marin Shockwave does not diagnose medical conditions, illnesses, or injuries of any kind.

■  Marin Shockwave does not prescribe medications, treatments, or medical therapies.

■  Marin Shockwave does not treat, cure, or claim to cure any medical condition, illness, or injury.

■  ESWT, EMTT, and EPAT sessions are provided solely for the purpose of symptom reduction and wellness support. These services are not a substitute for medical diagnosis, treatment, or care.

■  Clients are strongly encouraged to consult a licensed medical professional regarding any injury, illness, or medical concern.

3.  No Guarantee of Results

I understand that results from acoustic wave therapy vary from person to person and are not guaranteed. Marin Shockwave makes no representations or warranties — express or implied — that any session will produce a specific outcome, improvement, or cure.

4.  Limitation of Liability

I understand and agree that:

■  Marin Shockwave shall not be held liable for any adverse reaction, injury, discomfort, or negative outcome arising from or related to ESWT, EMTT, or EPAT sessions.

■  I assume full responsibility for my decision to receive these services and have had the opportunity to ask questions prior to treatment.

■  I acknowledge that I have disclosed all relevant health conditions, medications, implants, and contraindications to the best of my knowledge.

5.  Potential Risks & Side Effects

While acoustic wave therapies are generally considered safe, I understand that possible side effects may include:

■  Temporary soreness, redness, or bruising at the treatment site

■  Mild swelling or tingling sensations

■  Temporary increase in discomfort during or after treatment

■  In rare cases, skin irritation or minor tissue sensitivity

6.  Contraindications

I confirm that, to my knowledge, none of the following contraindications apply to me (or I have disclosed them below):

■  Blood clotting disorders or use of anticoagulant medications

■  Active malignancy or cancer at or near the treatment site

■  Pregnancy

■  Pacemaker or implanted electronic devices (relevant to EMTT)

■  Open wounds, skin infections, or acute inflammation at the treatment site

■  Corticosteroid injection within the past 6 weeks at the treatment site

Disclosed exceptions or additional health notes: ___________________________________________________

7.  Consent & Acknowledgment

By signing below, I confirm that I have read and understood this Informed Consent form in its entirety. I voluntarily consent to receive acoustic wave therapy services (ESWT, EMTT, and/or EPAT) from Marin Shockwave. I understand that these services are intended solely to support symptom reduction and general wellness, and are not a diagnosis, prescription, or cure for any condition. I release Marin Shockwave and its practitioners from liability for any negative outcomes associated with my sessions.

Marin Shockwave  •  This form is for wellness services only and does not constitute a medical record.