EMSELLA New Patient Intake Form

Patient contact information
Please use this format 000-000-0000
Emergency contact
Please use this format 000-000-0000
Family physician
Insurance information
Extended Health Insurance(s): Please check all that apply
Health history
Do you currently use incontinence products such as pads or undergarments?
Do you drink any of the following on a regular basis?
Your answers help us understand any other pelvic floor issues, symptoms, or dysfunction that you may be experiencing.
Pelvic Floor Symptoms: Please check all that apply
Your answers help us understand any other pelvic floor issues, symptoms, or dysfunction that you may be experiencing.

Contraindications to EMSELLA treatment

EMSELLA is amazing, but it is not for everyone.  Contraindications to treatment include but are not limited to:

  • Cardiac Pacemakers
  • Implanted Defibrillators
  • Other Electronic Implants
  • Pulmonary Insufficiency
  • Metal Implants
  • Drug Pumps
  • Malignant Tumor
  • Pregnancy

We will review the contraindications to with you again prior to commencing treatment.  For more information about contraindications to EMSELLA treatment please contact Pure Pelvic Health.