CONSENT FORM FOR EMFEMME TREATMENT

CONSENT FORM FOR EMFEMME TREATMENT
Name*

First NameLast Name
Date of Birth*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Primary Care Provider:*
Pronouns:
Reason for Seeking 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.
Initials*
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.
Initials*
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.
Initials*
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.
Initials*
On the day of the treatment, you are advised to wear comfortable clothing so the treatment area can be easily accessed.
Initials*
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.
Initials*

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