Men's Health Focused Shockwave Therapy Form

Focused shockwave for Men’s health conditions (Erectile dysfunction, Peyronie’s disease and Chronic pelvic pain syndrome).

Patient Name*

First NameLast Name

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Clinician

First NameLast Name

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Your Mobile Number

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Your Landline Number (unnecessary if mobile number provided)

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WHAT DOES FS DO?

Focused shockwave therapy is a non-invasive treatment in which a device is used to pass acoustic shockwaves through the skin to the affected area, it can be utilised in the treatment of many men’s health conditions including Erectile dysfunction, Peyronie’s disease and Chronic pelvic pain syndrome. The shockwaves stimulate the body’s own healing mechanisms to facilitate the repair of the damaged area.

A normal course of treatment will consist of between 4-8 sessions with a frequency of twice a week however, once a week is also clinically appropriate if you cannot commit to twice a week program. More sessions could be considered for chronic conditions.. More sessions could be considered for chronic conditions.

ADVICE

Following focused shockwave maintain ‘normal’ levels of activity. Do not do anything you normally would not do. Avoid sport, any other aggravating activities, or any activities, which stress the affected / treated area, particularly for the next 48 hours. Do not use ice on the treated area or take non-steroidal anti-inflammatory medicines (NSAIDS) e.g. ibuprofen, naproxen, as these may reduce the therapeutic effect of focused shockwave.

WHAT ARE THE SIDE EFFECTS?

The practitioner providing the treatment will have checked your medical history to ensure that you are at minimal risk of any side effects. These are as follows;

Most Common:

Skin infection
Reddening or bruising of the skin
Pain with erection
Bleeding whilst urinating
A transient increase in pain in the treated area, this can be controlled with paracetamol, please do not take NSAIDs e.g. ibuprofen, naproxen as this can reduce the therapeutic effect of the focused shockwave treatment.

Exclusion Criteria / Contraindications:

Steroid injection in the past month
Tendency to haemorrhage
Patients taking anti-coagulant therapy
Haemophiliac patients
Acute inflammation of the treatment area
Tumour at the treatment site
Infection of the treatment area
Severe circulatory disorder
Nerve disorder at treatment site
Open wound at the treatment site
Penile prosthesis
Radical prosthesis
Hypogonadism (reduced sex hormone production within the testes).

Pre-cautions: - Cardiac problems - Circulatory problems

Chaperoning

It is recommended that you bring a close family member or friend if possible. If you are not able to bring a chaperone with you to your appointment please inform your treating clinician prior to attending your appointment.

Signature (To draw your signature: Place the mouse cursor in the area below, click and hold the left mouse button then move the mouse as if you were drawing) *

I confirm that the practitioner has explained the information above and given me the opportunity to ask any questions. I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns. I agree to the procedure or course of treatment described on this form.*

Accept

Once we receive the completed form, this will then be screened by one of our senior clinicians. Once approved, one of our booking team will contact you to get you booked for an appointment – please note we aim to screen all consent forms within a maximum of 1-2 working days.

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