Votiva - Intake and Consent

Full Name

First NameLast Name

How did you hear about us?*

Which symptoms are you concerned with/looking to treat? (Select all that apply)*

Vaginal drynessLeaking or urinary incontinenceDecreased sexual desireDecreased sensation during intercoursePain or discomfort during intercourseWrinkling or sagging of the labia majora

Please list all current medications (including hormone replacement) *

Please list any drug allergies*

Date of last menstrual period*

Date of last PAP*

Was it normal?*

YesNo

Total number of pregnancies*

Total number of vaginal deliveries *

Relationship Status*

Do you have any of the following*

I duly authorize Dr. Jennifer Brooks and clinical staff to perform the Votiva Treatment

I confirm that I have informed the staff regarding any current or past medical condition, disease or medication taken.

I confirm that I have had a normal and up-to-date PAP test (within the past 12 months) and have communicated these results to the clinical staff.

I certify that I have been fully informed of the nature and purpose of the procedure, the expected outcomes and the possible complications and that no guarantee can be given as to the final result obtained.

I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, compliance with pre- and post-treatment instructions, and individual response to treatment.

I understand that while the risks associated with use of the Votiva device have been demonstrated to be minimal and are limited to the skin surface, there is a possibility of short term effects such as pain, discomfort, reddening, blistering, scabbing, swelling, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as infection, scarring and permanent discoloration.

I understand that failure to comply with pre- and post-treatment instructions may increase the probability of complications.

I understand that treatment with Votiva involves a series of treatments and the fee structure has been fully explained to me.

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 that I have read and fully understand the contents of this consent form.

Please sign here*

Vaginal Rejuvenation Intake and Consent

Informed Consent for Votiva Consent