FemTouch Consent

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I authorize Dr. Zimmerman/Dr. Lee and staff to perform fractional CO2 treatment on me in an effort to treat vaginal health-related symptoms related to menopausal transition to post menopause / other.

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The nature and effects of the procedure, as well as alternative methods of treatment have been fully explained to me and I understand them.

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I understand that there is a possibility of side effects or complications. I am aware that careful adherence to all advised instructions will help reduce this possibility.

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The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my related questions answered.

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Pre and post-care instructions have been discussed and are completely clear to me.

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I understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment. If no alleviation of vaginal health-related symptoms is observed or unsatisfactory resolution of my symptoms, I understand that it might be necessary or appropriate to revert to replacement therapies.

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I agree to review the following laser pre-treatment compliance checklist along with my physician and bring accurate and updated data, to the best of my knowledge.

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I understand the below list of possible short-term effects post procedure:

  • Itching
  • Redness
  • Swelling
  • Inflammation
  • Tenderness
  • Irritation
  • Burning upon urination
  • Spotting
  • Mild vaginal bleeding
  • Pink or brown vaginal discharge
  • Mild-to-profuse watery vaginal discharge
  • Discomfort

Please answer the following questions to the best of your abilities:

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Menses within the past year {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Discomfort related to vaginal laxity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Decreased vaginal lubrication {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sexually active {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Pain during sexual intercourse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Bleeding during sexual activity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Atypical vaginal /uterine bleeding {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Thick, whitish or yellowish vaginal discharge {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Pelvic floor surgery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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History of oestrogen therapy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Stress urinary incontinency {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Stinging during urination {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medical history of cancer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medical history of genital infections {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medical history of urinary tract infection {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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My signature certifies that I have duly read and understood the content of this informed consent form, and gave the accurate information as to my health condition. I hereby freely consent to the AcuPulse® FemTouch™ procedure.

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FemTouch Consent

FemTouch Consent

Patient First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I authorize Dr. Zimmerman/Dr. Lee and staff to perform fractional CO2 treatment on me in an effort to treat vaginal health-related symptoms related to menopausal transition to post menopause / other.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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The nature and effects of the procedure, as well as alternative methods of treatment have been fully explained to me and I understand them.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I understand that there is a possibility of side effects or complications. I am aware that careful adherence to all advised instructions will help reduce this possibility.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my related questions answered.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Pre and post-care instructions have been discussed and are completely clear to me.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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I understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment. If no alleviation of vaginal health-related symptoms is observed or unsatisfactory resolution of my symptoms, I understand that it might be necessary or appropriate to revert to replacement therapies.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I agree to review the following laser pre-treatment compliance checklist along with my physician and bring accurate and updated data, to the best of my knowledge.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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I understand the below list of possible short-term effects post procedure:

  • Itching
  • Redness
  • Swelling
  • Inflammation
  • Tenderness
  • Irritation
  • Burning upon urination
  • Spotting
  • Mild vaginal bleeding
  • Pink or brown vaginal discharge
  • Mild-to-profuse watery vaginal discharge
  • Discomfort

Please answer the following questions to the best of your abilities:

Date of las PAP smear: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Onset of meopause: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Menses within the past year {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Discomfort related to vaginal laxity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Decreased vaginal lubrication {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Sexually active {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Pain during sexual intercourse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Bleeding during sexual activity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Atypical vaginal /uterine bleeding {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Thick, whitish or yellowish vaginal discharge {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Pelvic floor surgery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
History of oestrogen therapy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Stress urinary incontinency {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Stinging during urination {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Medical history of cancer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Medical history of genital infections {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Medical history of urinary tract infection {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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List of additional current medication taken: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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My signature certifies that I have duly read and understood the content of this informed consent form, and gave the accurate information as to my health condition. I hereby freely consent to the AcuPulse® FemTouch™ procedure.

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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