FSM Consent

Frequency Specific Microcurrent Consent

authorize the Center for Holistic Medicine to perform the medical treatment known as Frequency Specific Microcurrent therapy(FSM).
This is a non invasive means of treating various conditions, including chronic pain. Your practitioner may recommend this treatment for off label uses of this device as there have been studies evolving in the literature supporting new uses. The equipment that we use is classified by the FDA as a TENS unit/device. TENS has not been shown to have any short or long term complications to date. However, the possibility that the device may affect some sensitive users in a presently unknown way cannot be overlooked.

I understand that FSM involves the use of physiologic (tiny) amounts of electric current(ie. Millionths of an ampere) applied to the body. I understand that there is no implied or stated guarantee of success or effectiveness of a specific treatment or series of treatments. However, I recognize that the chances of success are enhanced by following the directives of my clinician (for example, to be well hydrated on the day of my treatment). There are some people who may not be able to receive FSM therapy, including women who are pregnant and patients using demand type pacemakers. Please initial the following statements below:

It is important to make sure your practitioner is also aware of any recent injuries or surgery, even if they are minor in nature as this may change our treatment protocol.

Potential Risks: FSM has a history of safety and side effects are uncommon. If they do arise, they 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 electrical media when applied to the body, such as Ultrasound, EKG, etc, or to having a massage. These include irritation at the site of stimulation, soreness, fatigue, light-headedness, drowsiness or transient weakness. Symptoms may also worsen transiently before improving. Some treatments can result in transient dizziness. Microcurrent/TENS can induce seizures if there is a history of epilepsy.

Potential Benefits: Microcurrent therapy is painless, often increases speed of recovery, and often promotes healing in conditions that have not responded to other treatment. Microcurrent therapy can also lead to resolution of the health concern being treated and the inducement of a greater sense of well being. The effects are long lasting and occur without the side effects of pharmaceutical drugs.

I hereby release The Center for holistic Medicine from all liability in connection with the FSM therapy I receive. I understand that I am free to discontinue treatment at any time.

DISCLAIMER: By typing your name, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.