Risks of this Procedure

a) Petechiae or mild bruising. This usually subsides without treatment.

b) Pain and soreness. This is temporary and resolves after a week.

c) Tendon rupture and nerve injury. This is avoided with treatment with lower energy levels and by avoiding the nerve.

Consent for Procedure:

I, 'patient 'Undersigned, do hereby consent to authorize the application of Extracorporeal Shockwave Therapy (ESWT).

I have been fully informed of focal ESWT which use has been fully explained to me by my treating physician/staff, and I fully understand the nature of this treatment. I also confirmed that I have been given the opportunity to discuss and clarify any concerns and that no guarantees have been made to me as to the result/outcome of the treatment.

I have been advised that the treatment with ESWT will be mostly for pain relief and may offer an improvement of function. I also understand foregoing treatment is not the first option for my condition and an alternate treatment has either already been provided or offered to me.

Patient Signature: *

Clear

Patient, draw Signature in the box above.

Patient Signature Date: *

Name of the Parent / Guardian

Parent / Guardian Signature

Clear

Parent / Guardian, draw the signature in the box above.

Parent / Guardian Signature Date

Name of the Witness

Witness Signature:

Clear

Witness, draw the Signature in the box above.

Witness Signature Date: *

Terms & Conditions *

I agree to terms & conditions and by providing my phone number, I agree to receive text messages from the Shorewood Elite Integrated Healthcare.

900 Geneva St. Shorewood, IL 60404 (815)436-1988

Extracorporeal Shockwave Therapy Patient Consent Form

Risks of this Procedure