Extracorporeal Radial Shockwave Therapy Consent Form
Please review the following contraindications and check those which apply to you:
• Coagulation disorders, thrombosis, heart or circulatory patients
• Use of anticoagulants, especially Marcumar, Heparin, Coumadin
• Tumour diseases, carcinoma, cancer patients Pregnancy
• Polyneuropathy in case of diabetes
• Acute inflammations / pus focus in the target area
• Children in growth
• Cortisone therapy up to 6 weeks before first treatment
Possible side effects:
• Skin lesions after previous cortisone therapy
These side effects generally abate after 5 to 10 days. Pain can increase temporarily. Bruising and or swelling are also possible.
I agree to Extracorporeal Shockwave Therapy and understand the risks and possible complications involved.
Print Name__________________________ Date____________________________
Signature____________________________ Witness of Signature_____________________________