Emsella General Patient Record

Patient's Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Date Of Birth*

Date

Email*

example@example.com

TREATMENT CONSIDERATIONS

You are scheduled for a series of non-invasive treatments with the BTL EMSELLA device.
BTL EMSELLA is a non-invasive therapeutic device intended for stimulation of neuromuscular tissue. The
neuromuscular stimulation results in pelvic floor strengthening for treatment of urinary incontinence.

Your treatment provider will discuss your specific treatment needs. Recommended number of treatments
is 6. The treatment is typically about 30 minutes per session, with sessions separated by at least 2 days,
depending on your needs. Completing a full treatment 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.

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.

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.

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

	Yes	No
Pregnancy
Cardiac Pacemakers
Implanted defibrillators
Electronic Implants
Drug Pump
Hemonthagic Conditions
Anticoagulation Therapy
Heart Disorder
Malignant Tumor
Fever
Allergies To Medications
Any Surgeries
Any Skin Disease

I am aware that I can’t undergo the treatment when menstruating.

▪ 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.

▪ 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.

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

▪ 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.

▪ 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.

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