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You are scheduled for a series of non-invasive treatments with the EMFACE®. The EMFACE device used with EMFACE forehead and
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EMFACE cheek single use applicators is intended to provide heating for the purpose of elevating tissue temperature
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for selected medical conditions such as temporary relief of pain, muscle spasms, and increase in local circulation.
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Initials
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Your treatment provider will discuss your specific treatment needs. Four sessions are recommended, with 2–14 days between each
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session. The typical therapy treatment is generally about 20 minutes. Completing a full treatment series is necessary to
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maximize treatment efficacy. You may need additional treatments depending on the severity of your condition.
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Initials
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The area of interest should be free from hair. I acknowledge I have been advised to shave the area prior to the procedure
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or the area will be shaved at the procedure visit.
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Initials
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On the day of the treatment, you are advised to wear comfortable clothing so the treatment area can be easily accessed.
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Also, the treated area will be wiped with a cleanser before treatment to remove any moisture, perfume,
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moisturizers, or oils. You will be asked to remove all metallic accessories and electronic devices.
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Initials
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The treatment does not require anesthesia. During the application, you will feel muscle contractions and a heating
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sensation in the treated area. It is important to note that you should feel comfortable heat,
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but never feel an unpleasant burning or pain sensation during the treatment. Press the Therapy
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Discomfort Button any time should you feel any discomfort or pain. The procedure doesn’t require any recovery time.
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Typically, you can get back to your daily routine right after the treatment.
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Initials
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I am aware NOT TO wear any metallic accessories (such as jewelry, watch or clothes containing metallic threads or metallic
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accessories) during the treatment. I also acknowledge that I do not have any metallic or electronic
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implants near the treatment area (such as pacemakers, defibrillators, etc.).
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Initials
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Please answer whether you currently have or had any of the following in the past*:
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Bacterial or viral infection, acute inflammations
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Impaired immune system
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Isotretinoin in the past 12 months
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Skin related autoimmune diseases
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Radiation therapy and chemotherapy
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Poor healing and unhealed wounds in the treatment area
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Metal implants near treated area or neutral electrode
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Permanent implant near the area to be treated
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Pacemaker or internal defibrillator, or any other active electrical implant anywhere in the body
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Current condition or history of skin cancer, or current condition of any other type of cancer, or pre-malignant moles
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History of any type of malignant cancer
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Active collagen diseases
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Cardiovascular diseases (such as vascular diseases, peripheral arterial disease, thrombophlebitis, and thrombosis)
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Pregnancy/nursing or IVF procedure
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History of bleeding coagulopathies, use of anticoagulants
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Any active condition in the treatment area, such as sores, psoriasis, eczema, rash and rosacea
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Any surgical procedure in the treatment area within the last three months or before complete healing
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Poorly controlled endocrine disorders, such as diabetes
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Tuberculosis
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Hepatitis
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Febrile conditions
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Acute neuralgia and neuropathy
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Kidney or liver failure
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Sensitivity disorders in the treatment area
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Varicose veins, pronounced edemas
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Skin dermabrasion, skin resurfacing, or deep chemical peeling in the treatment area within 3 months prior to the treatment
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Electroanalgesia without exact diagnose of pain etiology
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Serious psychopathological disorders (such as schizophrenia)
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Neurological disorders( multiple cerebrospinal sclerosis, epilepsy)
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Scarring in the treatment area
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If you answer YES to any of these questions, please specify*:
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Treatment considerations
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I am aware that pregnancy and nursing is contraindicated, and pregnant women cannot undergo the treatment.
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Initials
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I am aware that as is the case with every heat-based therapy, in rare cases damage to natural skin texture
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(crust, blister, and burn) can occur.
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Initials
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I understand that there are certain side effects associated with EMFACE treatments. The side effects may include but are not
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limited to erythema, mild swelling, heating sensation, dry skin, temporary damage to
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natural skin texture (crust, blister, and burn), muscular pain, temporary muscle spasms.
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Initials
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I understand that the treatment may involve risks of complications or injury from both known and unknown causes, and I freely
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assume these risks.
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Initials
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I understand the results may vary from person to person and that an exact result cannot be predicted. Completing a full
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treatment series is recommended to maximize treatment efficacy. It is very unlikely, but it is possible that
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you will not feel any recognizable result after the procedure. I acknowledge the results may not meet my expectations.
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Initials
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I certify that I have read this entire document and that I agree with all provisions. I certify that I have had the opportunity
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questions and these questions have been answered in full to my satisfaction. I fully understand the treatment conditions, the
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procedure, and possible side effects.
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Initials
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I have read the above information, and I request and give my consent to be treated with the EMFACE by the physician(s) in this
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practice and his/her designated staff.
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Initials
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My signature below indicates that the above information is accurate and current.
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