• Votiva Intake and Consent

  • PATIENT INFORMATION

  • Date of Birth:*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • DRUG ALLERGIES

  • GYNECOLOGIC HISTORY

  • Menstrual periods:
  • Relationship Status:*
  • Are you sexually active?*
  • Current partners:
  • Pap smear result:

  • REVIEW OF SYMPTOMS

  • Which symptoms are you primarily concerned with?*
  • Do you have any of the following?*

  • CONSENT FOR VOTIVA TREATMENT

  • Votiva is a non-invasive treatment that restructures, restores and rejuvenates damaged vaginal tissues. By enhancing collagen reformation and revitalizing vaginal mucosa, Votiva reverses symptoms brought on by childbirth, aging, hormone imbalance, trauma, menopause, chemotherapy and radiation without the need for hormones or surgery.
    • 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.
  • Date:*
     - -
  • Should be Empty: