ThermiVa Consent

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I request and authorize Dr. Zimmerman or designated person to perform the following procedure utilizing temperature controlled radio frequency technology.

Radio Frequency treatment of the vulvo-vaginal region: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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The areas from treatment have been reviewed with me today and I am in agreement. I have been thoroughly and completely advised regarding the objectives of the procedure. I understand that the practice of medicine and surgery is not an exact science and although these procedures are effective in most cases, no results have been guaranteed. I acknowledge that imperfections might ensue and that the operative result may not live up to my expectations. I understand that clinical results may very based on many variables such as age, lifestyle, and current conditions.

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The treatment will involved applying heat to the vulvar and vaginal tissues using radio frequency for therapeutic purposes.

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I am aware of the following possible experiences and/or risks associated with the procedure:

  • Discomfort may be experienced during and/or after the treatment.
  • Possibility of over treating, resulting in painful intercourse
  • Some mild swelling and/or temporary redness may occur following the procedure.
  • Potential for transient over-active bladder
  • Injury to bowel and bladder
  • Scarring is rare, but it is a possibility if the skin surface is disrupter.
  • Although uncommon, burns can occur. And may require additional care at my own expense.
  • Infection (urinary tract, vaginal infection) is uncommon, but should it occur, treatment with antibiotics and/or surgical intervention may be required. Infection can further increase the risk of scarring. Proper wound care is important in prevention of infection. If signs of infection such as pain, heat, blisters, or surrounding redness develop, call the office immediately.
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While I understand this technology does not have any manufacturer declared contradictions, it is advised to not treat patients with the following conditions:

  • Cadiac devices such as AICD’s (auxiliary internal cardiac devices such as defibrillators, mechanical valves, pacemakers).
  • Pregnancy or nursing
  • Active Sexually Transmitted Diseases
  • Presence of an Intra Uterine Device (exception Mirena)
  • Current urinary tract infection
  • Pelvic pain and chronic dyspareunia (pain while having sex)

Your physician may suggest alternative treatment if you have any of the following conditions:

  • Greater than stage 2 organ prolapse
  • Thin rectovaginal septum
  • Recent vaginal surgery or fillers
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I consent to having clinical photographs taken before, during, and after my treatment. I understand that these photographs are an important part of my medical record.

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In addition, I consent to the use of these photographs, without my identity being revealed, for the education of future patients, professional clinical presentations, and medical journals.

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The nature and effects of the procedure, the risk, and the ramifications, complications, as well as alternative methods of treatment have been fully explained to me by the physician or designated person, and I understand them. The benefits of the proposed procedure, along with the probability of success have also been discussed with me. I have been given the opportunity to ask questions and have received satisfactory answers. I certify that I have read the above authorization and that I fully understand it.

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ThermiVa Consent

ThermiVa 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 request and authorize Dr. Zimmerman or designated person to perform the following procedure utilizing temperature controlled radio frequency technology.

Radio Frequency treatment of the vulvo-vaginal region: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Patient Initial {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

The areas from treatment have been reviewed with me today and I am in agreement. I have been thoroughly and completely advised regarding the objectives of the procedure. I understand that the practice of medicine and surgery is not an exact science and although these procedures are effective in most cases, no results have been guaranteed. I acknowledge that imperfections might ensue and that the operative result may not live up to my expectations. I understand that clinical results may very based on many variables such as age, lifestyle, and current conditions.

Patient Initial {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

The treatment will involved applying heat to the vulvar and vaginal tissues using radio frequency for therapeutic purposes.

Patient Initial {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

I am aware of the following possible experiences and/or risks associated with the procedure:

  • Discomfort may be experienced during and/or after the treatment.
  • Possibility of over treating, resulting in painful intercourse
  • Some mild swelling and/or temporary redness may occur following the procedure.
  • Potential for transient over-active bladder
  • Injury to bowel and bladder
  • Scarring is rare, but it is a possibility if the skin surface is disrupter.
  • Although uncommon, burns can occur. And may require additional care at my own expense.
  • Infection (urinary tract, vaginal infection) is uncommon, but should it occur, treatment with antibiotics and/or surgical intervention may be required. Infection can further increase the risk of scarring. Proper wound care is important in prevention of infection. If signs of infection such as pain, heat, blisters, or surrounding redness develop, call the office immediately.
Patient Initial {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

While I understand this technology does not have any manufacturer declared contradictions, it is advised to not treat patients with the following conditions:

  • Cadiac devices such as AICD’s (auxiliary internal cardiac devices such as defibrillators, mechanical valves, pacemakers).
  • Pregnancy or nursing
  • Active Sexually Transmitted Diseases
  • Presence of an Intra Uterine Device (exception Mirena)
  • Current urinary tract infection
  • Pelvic pain and chronic dyspareunia (pain while having sex)

Your physician may suggest alternative treatment if you have any of the following conditions:

  • Greater than stage 2 organ prolapse
  • Thin rectovaginal septum
  • Recent vaginal surgery or fillers
Patient Initial {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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I consent to having clinical photographs taken before, during, and after my treatment. I understand that these photographs are an important part of my medical record.

Patient Initial {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

In addition, I consent to the use of these photographs, without my identity being revealed, for the education of future patients, professional clinical presentations, and medical journals.

Patient Initial {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

The nature and effects of the procedure, the risk, and the ramifications, complications, as well as alternative methods of treatment have been fully explained to me by the physician or designated person, and I understand them. The benefits of the proposed procedure, along with the probability of success have also been discussed with me. I have been given the opportunity to ask questions and have received satisfactory answers. I certify that I have read the above authorization and that I fully understand it.

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