EMFACE Patient Treatment Record

Patient's Name

First NameLast Name

Date of birth

Phone Number

Phone number

You are scheduled for a series of non-invasive treatments with the EMFACE®. The EMFACE device used with EMFACE forehead and EMFACE cheek single use applicators is intended for aesthetic procedures such as facial rejuvenation and contouring by wrinkles reduction and skin laxity improvement by means of toning and lifting of muscles and skin

Your treatment provider will discuss your specific treatment needs. Four sessions are recommended, with 2–14 days between each session. The typical procedure is generally about 20 minutes. Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments depending on the severity of your condition.

The area of interest should be free from hair. I acknowledge I have been advised to shave the area prior to the procedure or the area will be shaved at the procedure visit.

On the day of the treatment, you are advised to wear comfortable clothing so the application area can be easily accessed. Also, the application area will be wiped with a cleanser before treatment to remove any moisture, perfume, moisturizers, or oils. You will be asked to remove all metallic accessories and electronic devices.

The treatment does not require anesthesia. During the application, you will feel muscle contractions and a heating sensation in the treated area. It is important to note that you should feel comfortable heat, but never feel an unpleasant burning or pain sensation during the procedure. Press the Therapy Discomfort Button any time should you feel any discomfort or pain. The procedure doesn’t require any recovery time. Typically, you can get back to your daily routine right after the treatment.

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

Signature*

Please answer whether you currently have or have had any of the following:*

	Yes	No
Bacterial or viral infection, acute inflammations
Impaired immune system
Isotretinoin in the past 12 months
Skin related autoimmune diseases
Radiation therapy and chemotherapy
Poor healing and unhealed wounds in the application area
Metal implants near application area or neutral electrode
Permanent implant near the area to be treated
Pacemaker or internal defibrillator, or any other active electrical implant anywhere in the body
Current condition or history of skin cancer, or current condition of any other type of cancer, or pre-malignant moles
History of any type of malignant cancer
Active collagen diseases
Cardiovascular diseases (such as vascular diseases, peripheral arterial disease, thrombophlebitis, and thrombosis)
Pregnancy/nursing or IVF procedure
History of bleeding coagulopathies, use of anticoagulants
Any active condition in the application area, such as sores, psoriasis, eczema, rash and rosacea
Any surgical procedure in the application area within the last three months or before complete healing
Poorly controlled endocrine disorders, such as diabetes
Tuberculosis
Hepatitis
Febrile conditions
Acute neuralgia and neuropathy
Kidney or liver failure
Sensitivity disorders in the application area
Varicose veins, pronounced edemas
Skin dermabrasion, skin resurfacing, or deep chemical peeling in the application area within 3 months prior to the treatment
Electroanalgesia without exact diagnose of pain etiology
Serious psychopathological disorders (such as schizophrenia)
Neurological disorders (such as multiple cerebrospinal sclerosis, epilepsy)
Blood vessels and lymphatic vessels inflammation
Scarring in the application area

Treatment considerations

I am aware that pregnancy and nursing is contraindicated, and pregnant women cannot undergo the procedure.
I am aware that as is the case with every heat-based procedure, in rare cases damage to natural skin texture (crust, blister, and burn) can occur.
I understand that there are certain side effects associated with EMFACE procedure. The side effects may include but are not limited to erythema, mild swelling, heating sensation, dry skin, temporary damage to natural skin texture (crust, blister, and burn), muscular pain, temporary muscle spasms.
I understand that the procedure 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. It is very unlikely, but it is possible that you will not feel any recognizable result after the procedure. I acknowledge the results may not meet my expectations.
I certify that I have read this entire document and that I agree with all provisions. I certify that I have had the opportunity to ask questions and these questions have been answered in full to my satisfaction. I fully understand the treatment conditions, the procedure, and possible side effects.
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 practice and his/her designated staff.

Patient Name: Patient Name Date Signed Date

Patient Signature*

Witness Name: Patient Name Date Signed Date

Witness Signature*

Practice Name

EMFACE Patient Treatment Record

If you answered YES to any of these questions, please specify: