Geneveve Screening & Consent - Fusion Medical Aesthetics

PATIENT INFORMATION

Site Name

Date of Screening

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 CRITERIA

At 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 FACTORS

Cardiovascular 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 CONSENT

In 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*

Witness Signature

Witness Name

First Last

Date

Geneveve Screening and Consent Form