CONSENT FORM FOR EMSELLA TREATMENT

Consent form for U1 Treatment
Name*

First NameLast Name
Date of Birth*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
PCP*
Pronouns
Reason for Seeking Treatment*
TREATMENT CONSIDERATION

You are scheduling a series of treatments with the BTL EMSELLA device. BTL EMSELLA is intended to provide entirely non-invasive electromagnetic stimulation of pelvic floor musculature for the purpose of rehabilitation of weak pelvic muscles and restoration of neuromuscular control for the treatment of urinary incontinence.
Initials*
Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 6. The treatment is typically about 30 minutes per sessions, with session separated by at least 2 days, depending on your needs. Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments depending on the severity of your condition.
Initials*
There is typically no pain associated with your treatment and there is no anesthetic required. You will experience a gradually increasing tingling feeling and muscle contractions. These sensations in the pelvic area are normal and expected. You remain fully clothed during the treatment.
Initials*
On the day of the treatment, you are advised to wear comfortable clothes which allow flexibility for correct positioning and increased comfort during the treatment.
Initials*

I am aware that pregnancy is contraindicated and pregnant women can't undergo the treatment.
Initials*
I am aware that I can't undergo the treatment when menstruating.
Initials*
I am aware there is a weight limit of 330 lbs. and I meet these requirements.
Initials*
I understand there are certain risks associated with BTL EMSELLA treatments and they include but are not limited to: muscular pain, temporary muscle spasm, temporary joint or tendon pain, local erythema or skin redness. I understand that the treatment may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks.
Initials*
I am willing to fill in forms and/or anonymous questionnaires if requested, as this will help for medical evaluation of the results of the treatment. Information will be acquired for medical records or marketing purposes.
Initials*
I understand the results may vary from person to person and that an exact result cannot be predicted. 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.
Initials*
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.
Initials*
I have read the above information, and I request and give my consent to be treated with the BTL EMSELLA procedure at Atkinson Family Practice.
Initials*
My signature below indicates that the above information is accurate and current.
Patient signature*

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Date*
Signature*

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Date*
Should be Empty:

	Yes	No
Pregnancy
Cardiac Pacemaker
Implanted defibrillators or implanted neurostimulators
Electronic implants
Pulmonary insufficiency
Metal implants
Drug pumps
Copper IUD (Paragard)
Malignant tumor

	Yes	No
Anticoagulation therapy
Heart disorder(s)
Allergy to any medications, food or other substances
Taking prescription, herbal, or over the counter medication
Pulmonary insufficiency
Any surgeries
Any skin disease or sensitivity
Bleeding disorder

Consent form for U1 Treatment