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Pelvic Zhush Consent Form

You are scheduled for a series of non-invasive treatments with the Pelvvic Zhush device.

The Pelvic Zhush is intended to provide entirely non-invasive electromagnetic stimulation of pelvic floor musculature for the purpose of rehabilitation of weak pelvic muscles and restoration of neuromuscular control for the treatment of urinary incontinence in women.

Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 6. The treatment is typically about 30 minutes per session, with sessions separated by at least 2 days, depending on your needs. Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments depending on the severity of your condition. The results will typically continue to improve over the next few weeks.

There is typically no pain associated with your treatment and there is no anesthetic required. You will experience gradually increasing tingling feeling and muscle contractions. These sensations in the pelvic area are normal and expected. You remain fully clothed during the treatment.   

On the day of the treatment, you are advised to wear comfortable clothes which allow flexibility for correct positioning and increased comfort during the treatment.

Acknowledgement
Please answer whether you currently have or have had any of the following:
Declaration

Please fill out the following form in order to participate in our Pelvic Zhush treatment program.

I am aware that pregnancy is contraindicated and pregnant women can’t undergo the treatment.
I am aware that I can’t undergo the treatment when menstruating.

Thanks for submitting!

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