avantemedicalcenter.com - General Patient Record and Demo Consent

Emsella Consent Form
Patient Name*

First NameLast Name
Date of Birth

MonthDayYear
Age
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
DEMO TREATMENT CONSIDERATIONS
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 in women.*
Initials
There is typically no pain associated with your treatment and there is no anesthetic required. You will experience 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
I am aware that pregnancy is contraindicated and pregnant women can’t undergo the treatment.*
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 have read the above information, and I request and give my consent demo a treatment with the BTL EMSELL Aprocedure by the provider(s) in the below stated practice and his/her designated staff.*
Initials
Please answer whether you currently have or have had any of the following
Pregnancy*

YesNo
Please Specify*
cardiac pacemakers*

YesNo
Please Specify*
implanted defibrillators, implanted neurostimulators*

YesNo
Please Specify*
electronic implants*

YesNo
Please Specify*
pulmonary insufficiency*

YesNo
Please Specify*
metal implants*

YesNo
Please Specify*
drug pumps*

YesNo
Please Specify*
hemorrhagic conditions*

YesNo
Please Specify*
anticoagulation therapy*

YesNo
Please Specify*
heart disorders*

YesNo
Please Specify*
malignant tumor*

YesNo
Please Specify*
fever*

YesNo
Please Specify*
allergy to any medications, food or other substances*

YesNo
Please Specify*
taking prescription, herbal, or over the counter medication*

YesNo
Please Specify*
any surgeries*

YesNo
Please Specify*
any skin disease or sensitivity*

YesNo
Please Specify*
My signature below indicates that the above information is accurate and current.
Patient signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Practice Name: Avante Medical Center, LLC
Should be Empty:

DEMO TREATMENT CONSIDERATIONS

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

My signature below indicates that the above information is accurate and current.