Kabir Center For Health

BTL EMSELLA

GENERAL PATIENT RECORD
Name*

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Date of Birth*

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Age*
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Email*
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Address*

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Diagnosis*
TREATMENT CONSIDERATIONS
You are scheduled for a series of non-invasive treatments with the BTL EMSELLA device.
BLT EMSELLA is intended to provide entirely non-invasive electromagnetic stimulation of pelvic floor musculature for the purpose of rehabilitation of weak pelvic muscled and restoration of neuromuscular control for the treatment of urinary incontinence in women.
Initials:   Signature*

Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 6. The treatment is typically 30 minutes per session, with sessions separated by at least 2 days, depending on your needs. Completing a full treatments series is necessary to maximize treatment efficacy. You may need additional treatments depending on the severity of your condition. The results will typically continue to improve over the next few weeks.
Initials:   Signature*

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:   Signature*

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:   Signature*

I am aware that pregnancy is contraindicated and pregnant women can't undergo the treatment.
Initials:   Signature*

I am aware that I can't undergo the treatment when menstruating.
Initials:   Signature

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:   Signature

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:   Signature

I understand the results may vary from person to person and that an exact result cannot be predicted. It is very unlikely but is possible that you will not feel any recognizable result after the procedure. I acknowledge the results may not meet my expectations.
Initials:   Signature

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:   Signature

I have read the above information, and I request and give my consent to be treated with the BTL EMSELLA procedure by the physician(s) in the below stated practice and his/her designated staff.
Initials:   Signature

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

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Witness Signature*

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PHOTO / VIDEO RELEASE
I hereby authorize Kabir Center for Health and/or other brands owned by Kabir Center for Health, to use my thoughts, comments, experiences, testimonial, treatment, or story for use in image, video, or still. I understand that my image may be edited, copied, exhibited, published or presented in presentation under any legal condition, including but not limited to: marketing, illustration, medical, scientific publication, social media, and web content. In addition, I understand that this material may be used within an unrestricted geographic area.

I agree that there will be no direct payment, royalties or other compensation offered to me by the company arising or related to the use of my image or recording.

I understand that I may revoke this photo/video release at any time by notifying Kabir Center for Health in writing within 48 hours of capture. The revocation will not affect any actions taken before the receipt of this written notification. Images/videos will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.

By signing this release, I acknowledge that I have completely read and fully understand the above consent for procedure and image release and agree to be bound thereby. I hereby release any claims against any person or company utilizing this material in compliance with the aforementioned restrictions.
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Child's Name (if applies)

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Guardian Signature (if applies)

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HIPAA CONSENT FORM
We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPPA NOTICE that is available to you at the front desk before signing this consent.

1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.

2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.

3. A patient’s written consent need only be obtained one time for all subsequent care given the patient in this office.

4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of these records for the care given proper to the written request to revoke consent but would apply to any care given after the request has been presented.

5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.

6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.

7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.

I give permission to the following individuals to have information regarding my medical condition or billing and insurance information
Name*

First NameLast Name
Relationship*
I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.
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Date*

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Date
Name*

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Email*
example@example.com
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BTL EMSELLA

TREATMENT CONSIDERATIONS

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

PHOTO / VIDEO RELEASE

HIPAA CONSENT FORM