Kegel Chair Consultation FormLet's get you back on track with this revolutionary treatment! Please note that all information provided by you in this form and during your consultation will be kept confidential. We value the privacy of our guests, and hope to ensure a comfortable and positive experience throughout!Name and Surname *Email Address *Phone *Date of Birth *Treatment ConsiderationsYou are scheduled for a series of non-invasive treatment sessions with the HIFEM (High Intensity Focused Electro-magnet) device. The Kegel Chair is intended to provide absolutely non-invasive electromagnetic stimulation of pelvic floor muscles causing contractions due to the pulses which strengthens and exercises the weak pelvic floor muscles, resulting in improved neuromuscular control of urinary incontinence.Recommended number of treatments are 8 sessions.The treatment is typically about 45 minutes per session, with sessions separated by at least 2 days. Completing a full cycle of 8 treatment sessions is necessary to maximize treatment efficacy to achieve lasting results. Depending on the severity of your condition more sessions might be needed. The results will typically continue to improve over the next few weeks of treatment.There is normally no pain associated with your treatment.There is also no anaesthetic or downtime after your session required. You will experience gradual increase of tingling 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. For example sports attire/ sport wear.Please indicate if any of the following apply to you: *PregnancyCurrently MenstruatingCardiac Pacemaker or Cardiac disordersCopper IUDMedicine pumpMetal Implants (especially knee and hip metal implants)Malignant TumoursMetal piercings in pelvic areaAny operationAny skin condition or sensitivityAnticoagulation therapyFeverOtherNone of the above.If your condition is not mentioned, please specify:Reason for treatment *Stress IncontinenceUrge incontinenceCombined incontineceHyperactive bladderProlapsed bladderGeneral strengtheningNone of the aboveMultiple reasons can be marked.Do you have any questions or concerns about the treatment?Consent & Indemnity ( Please read all points before checking the consent box) * 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. I understand there are certain risks associated with HIFEM Kegel chair treatments and they include but are not limited to: muscular pain, temporary muscle spasm, temporary joint or tendon pain, local erythema or skin redness. I understand that the treatment may involve risks of complications or injury from both known and unknowncauses, and I freely assume these risks. I am willing to fill in forms and/or anonymous questionnaires if requested, as this will help for evaluation of theresults of the treatment. Information will be acquired for testimonial records or marketing purposes. I understand the results may vary from person to person and that an exact result cannot be predicted. It is veryunlikely but it is possible that you will not feel any recognizable result after the procedure. I acknowledge theresults may not meet my expectations. I certify that I have read this entire document and that I agree with all provisions. I certify that I have had theopportunity to ask questions and these questions have been answered in full to my satisfaction. I fully understand the treatment conditions, the procedure and possible side effects. I have read the above information, and I request and give my consent to be treated with the HIFEM Kegel chair procedure by the personnel in the below stated enterprise and his/her designated staff. My signature certifies that I have duly read and understood the content of this informed consent form, and have given the accurate information as to my health condition. How much does leaking urine interfere with your everyday life on a scale of 0-7. *0 - Never. No urine leakage1 - Leaks just before getting to the Restroom2 - Leakage when coughing or sneezing3 - Leakage when asleep4 - Leakage when physically active/exercising5 - Leakage after urinating6 - Leakage for no obvious reason7 - Leakage all the timeThis information is confidential.Weight in KgSigned By *Initials *Date signed *TERMS & CONDITIONSTerms & Conditions for the Spa can be found HERE on the first page of our Spa Menu. Please read through them before acceptingI have read the above information and have provided accurate information. If I have any concerns, I will address these with my beautician. I give permission to my beautician to perform the treatments we have discussed and will hold him/her harmless from any liability that may result from this treatment. I understand that my beautician will take every precaution to minimize or eliminate negative reactions as much as possible, an accept the Terms & Conditions of The Feather Hill's Day Spa. *YesPlease upload a photo or pdf of your ID document as consent for the above.Choose FileNo file chosenDelete uploaded fileSend Message
