arcticmedicalcenter.com - Gainswave Intake

Gainswave® Intake
Patient Name:

First NameLast Name
DOB:

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Phone Number:
Please enter a valid phone number.
Email:
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Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What area(s) of improvement are you interested in?
List any ED medications you are currently taking or have used in the past:
Did they work?
List any conditions/medical history you currently have or have had in the past:
List any known allergies:
When was the last time you saw a doctor for a physical exam?
List all medications and supplements you are currently taking:
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of the staff responsible for any errors or omission that I may have made in the completion of this form.
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Date:

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Contraindications for Treatment
Patient Name:
DOB:

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Date
Please read carefully and follow instructions before your treatments.
Please mark if you have any of the following conditions

Coagulation disorderHistory of thrombosisAre on blood thinners (anticoagulants)History of cancer – especially prostate or penile cancerActive or recent infectionActive or recent sexually transmitted infectionLesions or sore on or near treatment areaPenile implant
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Date

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*If using numbing cream, note that numbness may remain for 4-5 hours after procedure

For best results discontinue use of anti-inflammatory agents 2 weeks prior to treatment; these include but are not limited to:
- Aspirin (ASA)
- NSAIDs (Motrin, ibuprofen, Aleve, Advil, etc.)
- Essential fatty acids (EPS, DHA)
- Vitamin A
- Turmeric
- Garlic
- Ginger
- Cayenne Pepper
Patient Signature

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Date

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Should be Empty:

Gainswave® Intake