EMSELLA New Patient Intake

Name(Required)
Date of Birth(Required)
Address(Required)
Emergency Contact Name(Required)
Family Physician
Extended Health Insurance(s) Please check all that apply(Required)
Pelvic Floor Symptoms (Please check all that apply)
Your answers help us understand any other pelvic floor issues, symptoms or dysfunctions that you may be experiencing.

Contraindications to EMSELLA treatment

EMSELLA is amazing, but it's 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. For more information about any contraindications please call Pure Pelvic Health.