SoftWave Experience Day Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What area of Body would you like to discuss treatment of?
*
Do you have or have you had any of the below:
Rows
Yes
No
Skin Infection
Cardiac Pacemaker
Cortisone Injection in the last 30 days
Taking NSAIDS or anti-coagulant treatment
Bleeding Disorder
Organ Transplant
Dialysis
Blood Pressure Medication
Blood Thinner Medication
Gastric Bypass Surgery
Chemo-Induced Neuropathy
Choose an available appointment time for your FREE Softwave DEMO!
*
I understand I must provide a 48 hour notice directly to our office at 651-388-8113 if I can not attend my scheduled appointment.
*
Yes
Insurance companies do NOT deem this service medically necessary. Please sign below that you understand this statement. Risks of procedure: Petechia or mild bruising. This usually subsides without treatment. Pain and soreness may occur but usually resolve after a week. I undersigned, do herby consent to authorize the application of ESWT for my condition. I have been fully informed of the focal ESWT which it's use has been fully explained to me by my treating physician and staff. I full understand the nature of this treatment. I also have confirmed that I have been given the opportunity to discuss and clarify any concerns and no guarantees have been made to me mostly for pain and relief and improvement of function. I also understand foregoing treatment is not the first option for my condition and an alternate treatment has either been already provided or offered to me
*
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