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Emsella Pre-Treatment Evaluation and Consent Form

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Emsella Pre-Treatment Evaluation and Consent Form

This form is to evaluate if the Emsella treatment is right for you and to obtain your informed consent for the procedure. Please read each section carefully and answer all questions honestly.

Patient Information

Please fill out the following information:

Medical History

Please answer the following questions about your medical history:

Emsella Treatment Information

For more information of what the Emsella treatment is please visit this link where we explain this in detail: Click here

Consent and Precautionary Measures

Essential information regarding the Emsella Pre-Treatment Evaluation and Consent process.

  • This treatment is not suitable for pregnant individuals.
  • Treatment should be scheduled outside of menstrual periods.
  • Please wear loose, comfortable attire to ensure ease of movement during the session.
  • Avoid wearing any metallic items, including jewelry, watches, and garments with metallic elements.

Patients Who Should Not Undergo Emsella Treatment Include but not limited to:

  • Individuals with metal or electronic implants.
  • Those who have cardiac pacemakers, implanted defibrillators, neurostimulators, or drug pumps.
  • Pregnant women.
  • Individuals with pulmonary insufficiency.
  • Patients who have undergone recent surgical procedures in the treatment area (within the past six weeks).
  • Those currently experiencing temporary muscle spasms.

Possible Side Effects

  • Muscular pain.
  • Temporary muscle spasm.
  • Temporary joint or tendon pain.
  • Local erythema (skin redness).

Additional Information

  • To achieve optimal results, a complete course of 6 Emsella sessions is recommended. Further sessions might be needed depending on the individual's specific situation.
  • It's important to understand that results are individual and cannot be guaranteed.
  • There's a possibility that the treatment might not yield noticeable changes for some individuals.
  • Emsella is a non-surgical treatment. It should be noted that its outcomes will differ from those of invasive surgical interventions.
Consent

I have read and understood the information provided about the Emsella treatment. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction. I consent to the Emsella treatment.