Emerald® Laser System Treatment Guidance Form

  • Emerald® Laser System Treatment Guidance Form

  • You have requested to be treated with EMERALD LASER SYSTEM, a low-level laser manufactured by Erchonia Corporation.

    This treatment involves the application of a 532 nm low intensity laser for the disruption of adipocyte cells within the fat layer for the release of fat and lipids from these cells for non-invasive aesthetic use. In contrast to high-power, high heat lasers that are used in various medical procedures, the low level laser used for this treatment is a "cold" laser and has no thermal effect on tissue.

    EMERALD LASER SYSTEM has been approved by the FDA as both safe and effective for the reduction of circumference of the hips, waist, thighs and the appearance of cellulite. Though safe and non-invasive, any medical or cosmetic procedure carries risks, complications and varied results as to its effectiveness. The purpose of this document is to make you aware of the nature of this product and its risks in advance so that you can decide whether to go forward with this procedure (no side effects have been reported to date).

    During EMERALD LASER SYSTEM treatments, there will be no discomfort and you will not feel the laser. However, the light will be visible. There are few risks associated with low-level laser therapy. The only known risk with the use of this device is that long-term exposure to laser light may cause damage to your eyes if unprotected. You will be provided with protective eyewear during your procedure and you must wear them throughout your treatment to avoid any possible risk.

    It is possible that you may not see any improvement in your body contour or appearance of cellulite if you don’t follow what your doctor/practitioner tells you, or if you don’t disclose full lifestyle or medical history information at this consultation. The EMERALD LASER SYSTEM works by reducing the fatty content from your fat cells in the area treated, and does not remove or kill the fat cell. Eating poorly, not exercising properly and gaining weight will likely reverse the results of your treatment as the fat may re-accumulate in your fat cells.


  • I understand this is an elective, cosmetic procedure and that the prescribed series of treatments is required to achieve desired results. I understand the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the results of this procedure. I understand that I must follow the pre and post treatment regimen as prescribed by     and staff, including:

  • PATIENT RESPONSIBILITIES

    - Stay hydrated (drink at least 2 litres of water each day)

    - Minimise consumption of alcohol, caffeine and fizzy drinks

    - Adhere to eating healthily

    - Exercise as outlined in the Patient Procedure Guide (small lifestyle changes, like walking where possible)

    - Lymphatic Stimulation (massage, lymphatic suit, vibration plate, etc)

    - Failure to follow the outlined Patient Protocol may result in failure to achieve the anticipated results.

    There have been no reported side effects or adverse reactions associated with any of the Erchonia Laser Systems. It is up to your doctor/practitioner to do a thorough analysis to see whether he/she feels you are a suitable candidate for this treatment.

    There are certain conditions which MAY affect the ability of the laser to deliver an acceptable result.

  • Contraindications

  • Treat with caution

  •    and staff have explained EMERALD LASER SYSTEM low level laser and its risks, benefits and alternatives, including not doing the procedure, and have answered all my questions about this procedure. I therefore consent to having EMERALD LASER SYSTEM low-level laser treatments.

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