Patient Contact Information

Full Name:

Email:

Phone Number:

Clinic Name:

HydroWave Screening Questions

Are you using a cardiac pacemaker or implantable medical device?

YESNO

Do you have a severe infectious disease?

YESNO
If yes, what kind and where?

Do you have a severe bleeding disorder/tendency or are you on anticoagulant treatment?

YESNO
If yes, which ones?

Have you been injected with cortisone within the last 30 days?

YESNO
If yes, where?

Do you have a complete tear in the tendon?

YESNO
If yes, where?

If you are pregnant, is your complaint area near your fetal tissue?

YESNO

Complaint areas of trunk between T4 and through the bilateral hips cannot be treated (spine below T4, ribs below T4, lumbar spine, Iliums, sacrum/coccyx, all surrounding tissue)

If you have been diagnosed with cancer or tumor, has it metastasized or is it systemic?

YESNO

Do you have unmanaged severe high blood pressure (180+ systolic / 120+ diastolic)?

YESNO

If you are under 18 years old, is your complaint area a growth plate?

YESNO

Long bone growth plates include Ilium, femur, humerus

Consent for HydroWave Therapy

The HydroWave benefits will be explained by your doctor.

Risks: Local discomfort, soreness, bruising, increase in pain. During treatment, patients may experience minimal decrease in sensation, nausea, tingling, headaches, or fainting.

I have read or reviewed the above questions and heard aloud the warnings and contraindications. I have discussed it with the doctor and have had my questions answered to my satisfaction. By signing below, I state that I have weighed the risks involved in undergoing treatment and I have decided that it is in my best interest to undergo the treatment recommended. I, the undersigned, hereby grant full permission to HydroWave, its employees, representatives, agents, licensees, and assigns (collectively referred to as the “Practice”) to photograph, video record, and/or audio record me, and to use, reproduce, edit, publish, display, distribute, and otherwise use my image, likeness, voice, and/or statements, in whole or in part, for any lawful purpose, including but not limited to promotional, educational, marketing, advertising, commercial, or informational purposes in any medium or format now known or later developed, including but not limited to print, digital, social media, websites, and broadcast media.

Signature:

Date: