Votiva Intake and Consent
PATIENT INFORMATION
Patient Name (last, first, M.I):
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
*
Home Phone:
Format: (000) 000-0000.
Cell Phone:
*
Format: (000) 000-0000.
Email:
*
example@example.com
Mailing Address:
*
Social Sec. #:
How did you hear about us:
*
DRUG ALLERGIES
Allergy:
*
Reaction:
MEDICAL PROBLEMS:
*
List any medical conditions
CURRENT MEDICATIONS:
*
Include the name, strength/dose, & frequency taken for all prescribed, over-the-counter drugs, hormones, vitamins, supplements, inhalers, etc.:
GYNECOLOGIC HISTORY
Total Pregnancies
*
Total Children
*
Full Term
Premature
Miscarriages
Abortions
Menstruation started at age:
Menopause started at age:
Last menstrual period (first day):
*
Menstrual periods:
Regular
Irregular
Relationship Status:
*
Single
Married
Partnered
Separated
Divorced
Widowed
Are you sexually active?
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Yes
No
Current partners:
Male
Female
Both
When was your last pap smear? (month/year):
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Pap smear result:
Normal
Abnormal
REVIEW OF SYMPTOMS
Which symptoms are you primarily concerned with?
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Vaginal Dryness
Leaking or urinary incontinence
Laxity, relaxation, looseness of the vagina
Decreased sexual desire
Decreased sensation/sensitivity during intercourse
Pain or discomfort during Intercourse
Wrinkling or sagging of the labia majora
Do you have any of the following?
*
Anemia
Autoimmune Disorder / Impaired immune system
Blood / Bleeding / Clotting / Scarring Disorder
Cancer / History of cancer
Chest Pain
Currently Pregnant / Nursing
Diabetes
Easily Bruise
Herpes
Metal Implants (including IUD)
Pacemaker / Defibrillator
Vaginal or pelvic surgery within the past 12 month
Menopause
Hysterectomy
None
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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.
Signature:
*
Date:
*
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Month
-
Day
Year
Date
Submit
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