ESWT TREATMENT CONSENT FORM

I do hereby give my consent to be treated with ESWT (Extracorporeal Shock Wave Therapy) with the Sonocur ® Basic shock wave device:(Required)

Patient First Name Patient Last Name

Patient Phone Number(Required)

Patient Email:(Required)

For treatment of my condition:(Required)

Physicians diagnosis and/or site to be treated here!

As prescribed by:(Required)

Physician's name who ordered treatment here!

I have read and understand the “Patient information for Treatment with Sonocur^® Basic”. I understand the treatment that I am to receive and why it has been prescribed and how it works.
I understand that if I am currently taking anticoagulant medication (blood thinners), have a bleeding disorder, or if I am pregnant or under the age of 18 years that I should not be treated unless cleared in advance in writing by the treating Physician.
I understand that I may experience the following adverse events or side effects from Sonocur^® Basic ESWT treatment:

Pain or discomfort at the treatment site during and immediately after treatment. This pain usually resolves immediately upon completion of the treatment session.
Nausea, sweating, dizziness, tremor, and paleness, or temporary widening of the blood vessels. These events, when they occur, are generally mild in severity and resolve quickly without any treatment.
Reddening of the skin or bruising at the treatment site, although very rare, usually clears within a few days.
Muscle pain (myalgia) or muscle tension (hypertonia) at or around the treatment site. This can include soreness, cramps, or spasm. When these effects, occur, most are mild in severity and resolve within 48 hours without treatment.
Joint stiffness. This again is very rare but if it occurs, it usually resolves within 48 hours without any other treatment.
Tingling or numbness sensations at the treatment site. These adverse events usually resolve without treatment.

I understand that although not seen in the Sonocur^® Basic clinical studies, other potential adverse events seen with similar devices include: 1. Neuropathy (problem with the nerves), 2. Tendon rupture, 3. Local hematoma (bruising or localized collection of blood near treatment site), 4. Misdirection of energy.
I understand that although I may get immediate relief of my pain, most patients do not get maximum improvement until 8 to 12 weeks after the last treatment session.
I understand that some patients may get no relief or improvement from this treatment.

Date signed:(Required)

Schedule a Consultation