CONSENT FORM FOR EMFEMME TREATMENT

Please initial each of the below to show your understanding.

 

TREATMENT CONSIDERATIONS:

You are scheduled for a series of internal and/or external treatments with the EMFEMME 360.  This device is intended to provide heating for the purpose of elevating tissue temperature for selected medical conditions such as temporary relief of pain, muscle spasms, and increase in local circulation of the vagina.

Your treatment provider will discuss your specific treatment needs.  We recommend three sessions, one every other week for three total treatments.  You may need additional treatments depending on the severity of your condition.  For optimal health, it is important to follow the treatment plan that has been established for you.

The area of interest should be free from hair.  I acknowledge I have been advised to shave the area prior to procedure for treatment to take place.

Before the treatment, you are not required to do anything special; however, keeping your body well hydrated is strongly recommended.  You will also be asked to remove any jewelry from the treatment area.

On the day of the treatment, you are advised to wear comfortable clothing so the treatment area can be easily accessed.

I acknowledge that successful treatment outcome can be affected by smoking or excessive alcohol consumption; same as by eating disorders, on-going medication, or insufficient hydration.  While no special diet is required, you are encouraged to eat healthy to help promote and maintain results.

I am aware NOT TO wear any metallic accessories (such as jewelry, watch or clothes containing metallic threads or metallic accessories) during the teatment.  I also acknowledge that I do not have any metallic or electronic implants (such as pacemakers, defibrillators, metallic IUDs, etc).

Please answer whether you CURRENTLY have any of the following:

TREATMENT CONSIDERATIONS:

I am aware that pregnancy is contraindicated and pregnant women cannot undergo treatment.

I understand that there are certain side effects associated with EMFEMME 360 treatments.  The side effects may include, but are not limited to erythema, very intense heating sensation or mild pain and dry skin.  I fully understand the treatment conditions, the procedure, and the possible side effects.

I understand that the treatment may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks.

I understand the results may vary from person to person and that an exact result cannot be predicted.  Completing a full treatment series is recommended to maximize treatment efficacy.

I have read the above information, and I request and give my consent to be treated with the EMFEMME 360 by the physician(s) in this practice and their designated staff.

My signature below indicates that the above information is accurate and current:

FOR OFFICE USE ONLY