Alma Duo Consent
Fill out this form to be eligible for receiving Alma Duo Treatment at RevolutinaryMD!
Date of Birth
For men’s treatment: penile shaft and perineum (area between scrotum and anus)
For women’s treatment: Clitoris and surrounding area.
I consent to Dr. Grover and/or for his certified staff to perform the Almo Duo procedure today and for the additional treatments in a series as recommended.
I understand that Almo Duo is a device used to stimulate blood flow and that clinical results may vary with different patients. I understand there is a possibility of short-term effects such as mild local swelling or redness, local pain or discomfort, small bruising under the skin, temporary tingling or numbness feeling in the area, as well as rare side effects such as skin
irritation and/or redness due to an allergic reaction to the ultrasound gel which is used during the procedure. I will notify the office should I have any of the following concerning side effects.
I recognize these potential side effects and will inquire with Dr. Grover or his staff should I have any other questions or concerns. Clinical results may vary depending on individual factors, including medical history, certain medication patient compliance with post-treatment instructions, an individual response to treatment. I understand that treatment by the Almo Duo system involves a series of treatments and the fee structures have been fully explained to me. At least 5-6 treatments are needed to see a significant response.
I have been fully informed of the nature and the purpose of the procedure, expected outcomes, and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of an elective concern and that the decision to proceed is based solely on my expressed desire to do so. I certify that I have
been given the opportunity to ask questions and I have read and fully understand the contents of this consent form.
By signing below, you consent to and agree with all of the statements listed above.
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