Geneveve Screening and Consent Form PATIENT INFORMATIONSite Name Date of Screening MM slash DD slash YYYY Screening Caregiver Name Treating Practioner Name Patient Name* First Last Blood pressure (systolic/diastolic) Height* Weight* Number of Vaginal Births* Time since last Vaginal Birth* SCREENING CRITERIAAt least 18 years of age* Yes No Pre-menopausal* Yes No Had at least one vaginal delivery* Yes No Normal pap smear within last 12 months* Yes No Currently sexually active (at least once/month)* Yes No Intact perineal body* Yes No Dissatisfied with change in amount of sensation or "tightness" during sexual intercourse* Yes No Currently pregnant* Yes No Significant vaginal prolapse* Yes No Dyspareunia* Yes No Active vulvar-vaginal medical condition (e.g. yeast, warts, herpes)* Yes No Medical problems that might interfere with woundhealing process* Yes No Undergoing chemotherapy, radiation, or pelvic floor therapy* Yes No Implantable electrical device* Yes No COMORBIDITY/RISK FACTORSCardiovascular Disease* Yes No Smoker/COPD* Yes No Type 1 / Type 2 Diabetes* Yes No Hypertension* Yes No Chronic use of drugs that may impede neo-collagenesis (e.g., anti-inflammatories)* Yes No Use of drugs that may affect sexual function (e.g., anti-depressants)* Yes No Treatment at discretion of provider. Note: Device has not been evaluated for use in: • Post-menopausal women, or • Women who have NOT had at least one vaginal delivery.PATIENT CONSENTIn considering a treatment, please read the following information carefully and discuss any questions you may have with your physician. It has been explained to me that the device delivers a low amount of radiofrequency energy to the tissue inside the vagina near the opening. While there is no downtime, the tissue may be tender from the surface cooling applied during the treatment. Therefore I understand it is important to follow my doctor’s timeline for refraining from intercourse or insertion of tampons so as not to irritate the area. It has been explained to me that the results vary from person to person given the amount of tissue laxity and my body’s own natural response to the treatment. I also understand I may not start to feel a difference until approximately one month after treatment and that the results will build gradually in the months following. It has been explained to me that the non-surgical treatment is not intended to provide the same results as a surgical procedure. I understand that increased friction resulting from tightening of the vaginal opening is one of many factors contributing to sexual satisfaction. I have read and understand all the information presented and I authorize to receive the Geneveve Treatment from the following practice: Dr. Lisa Gardner/FUSION MEDICAL AESTHETICS.Patient Signature*Patient Name* First Last Date* MM slash DD slash YYYY Witness SignatureWitness Name First Last Date MM slash DD slash YYYY
