New Patient Intake
Informed Consent Form
Name
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First Name
Last Name
Age
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Date of Birth
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-
Month
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Day
Year
Date
Gender
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Male
Female
Email
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example@example.com
Phone Number
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Please select the treatment(s) you are receiving today:
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Emface (Minimum 4 sessions) A non-invasive facial treatment combining radiofrequency and High-Intensity Facial Electromagnetic Stimulation (HIFES) to lift and tone facial muscles, reducing wrinkles.
Emsculpt Neo (Minimum 4 sessions) A body contouring treatment that combines High-Intensity Focused Electromagnetic (HIFEM) energy and radiofrequency to build muscle and reduce fat.
Exion (Face/Body/Fractional RF) (Minimum 4 sessions) A treatment utilizing radiofrequency energy to remodel and smooth the skin, stimulating collagen and elastin production
Emsella (Minimum 6 sessions) A non-invasive treatment using High-Intensity Focused Electromagnetic (HIFEM) technology to strengthen pelvic floor muscles, addressing urinary incontinence.
Emtone (Minimum 4 sessions)A therapy combining radiofrequency and targeted pressure energy to treat cellulite and improve skin elasticity.
Are you currently taking any medications (supplements, vitamins, contraceptives, etc.)? If yes, please list them below and the reason why you're taking it.
If you have an IUD, please specify the material or type
Did you undergo any surgery or cosmetic procedures in the past 12 months? If yes, please indicate the name of the procedure.
Please notate if you've received Botox in the past 2 weeks or filler within the last 8 weeks
Have you been hospitalized in the last 12 months? If yes, please provide the date and the reason why you were admitted.
General Information & Procedure
You are scheduled for a non-invasive or minimally invasive treatment with the selected device(s). Your treatment provider has discussed the specific protocol for your chosen procedure, including recommended sessions and post-treatment care. Completing the full series of treatments is advised to maximize efficacy. Individual results may vary, and no guaranteed outcome can be promised.
Please read and check each item to confirm your understanding and compliance:
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I will arrive well-hydrated for optimal comfort and efficacy
I will wear comfortable clothing to allow easy access to the treatment area
The treatment area must be free of hair, lotions, makeup, or oils before the session
I will remove metallic accessories and electronic devices prior to treatment
I understand that certain treatments require multiple sessions to achieve optimal results
I acknowledge that some treatments require shaving of the area prior to treatment
I understand that for heat-based treatments, I may experience warming sensations, but should not feel pain. If discomfort occurs, I will notify my provider immediately
I am aware that some treatments involve electromagnetic stimulation, which is contraindicated if I have pacemakers, defibrillators, or other metal implants
I acknowledge that smoking, alcohol consumption, and certain medications may impact my treatment results
I understand that muscle-stimulating treatments may cause temporary soreness, spasms, or mild discomfort
I acknowledge that heat-based treatments carry a minimal risk of burns, redness, or texture changes, and I will follow post-treatment care instructions
I will disclose all recent surgeries, active skin conditions, or any medical concerns prior to treatment
I understand that treatment outcomes vary by individual and that no guarantees of specific results are made
I acknowledge that photographs are required for medical records and insurance purposes and will remain confidential unless I provide written consent for marketing use
I will follow pre and post-treatment instructions to optimize results
I will notify my provider of any discomfort, side effects, or concerns immediately
While generally safe, these treatments may have side effects, including but not limited to:
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Temporary redness, swelling, mild pain, muscle spasms, or sensitivity in the treated area
Heating sensation, which should remain comfortable—inform your provider of any discomfort
Blistering, burns, or skin texture changes (rare, associated with heat-based treatments)
Temporary weakness or soreness after muscle stimulation treatments
Increased menstrual flow (for certain muscle-based therapies)
Please check if you have or have had any of the following Contraindications or Medical Conditions:
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Pacemaker, internal defibrillator, or other active electrical implant
Metal implants, including but not limited to joint replacements, screws, plates, rods, or dental implants
Metal or copper containing IUD or contraceptive device
Permanent implants of any kind (e.g., neurostimulators, drug pumps)
Pregnancy, nursing, or undergoing IVF treatment
Cardiovascular diseases, blood disorders, or clotting issues
Active cancer, history of cancer, or pre-malignant moles
Skin conditions such as eczema, rash, rosacea, or infections in the treatment area
Poorly controlled diabetes or other endocrine disorders
Any recent surgery or unhealed wounds in the treatment area
History of keloid scarring, poor healing, or sensitivity disorders
Neurological disorders such as epilepsy or multiple sclerosis
Liver or kidney disease
Any use of blood thinners, anticoagulants, or recent history of blood clots
Any active infections, fever, or immune system compromise
If you checked any of the above, please provide additional details for your provider
Legal Disclaimer and Release of Liability
I acknowledge that this treatment is elective and not medically necessary. I understand that Berzin Aesthetics, its medical staff, and Dr. Bella Berzin make no guarantees regarding treatment results. I understand that results may vary from person to person and that multiple sessions may be required for optimal outcomes. I release Berzin Aesthetics, Dr. Bella Berzin, and affiliated staff from any liability related to the effectiveness of my treatment or potential side effects.
Treatment Acknowledgment and Consent
By signing below, I confirm that I have read and understood this consent form. I have had the opportunity to ask questions, and all my concerns have been addressed to my satisfaction. I acknowledge the risks, benefits, and limitations of my selected treatment(s) and consent to proceed.
Patient Acceptance
Name
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First Name
Last Name
Signature
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Submit
Submit
Medical Director - Treatment Plan Approval
Our Medical Director is currently reviewing your treatment plan for approval. If there are any medical concerns or contraindications, we will contact you for clarification. You will receive confirmation upon approval.
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