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Wasabi Method

Radial Shockwave Therapy


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Please check what applies to you*
Pre-ruptured tendons
Current or possible pregnancy
Under 18 years of age
Blood-clotting disorder
On oral anticoagulants
Local tumors or bacterial and/or viral infections
Recent local cortisone injection (within 6 weeks)
None of the above
First Client Name
First Name*
Last Name*
Phone*
First Client Date of Birth*
Date of Birth
Information

I hereby acknowledge that I have been thoroughly informed about the proposed treatment, including its potential benefits, risks, and any contra-indications relevant to my medical condition. I understand that there are inherent risks associated with the procedure, including but not limited to temporary discomfort or pain, bruising or redness, nerve irritation. Despite these potential risks, I hereby voluntarily consent to undergo the proposed treatment. I understand that I have the right to ask questions and seek further clarification at any stage. By signing below, I acknowledge that I am providing my informed consent for the treatment.

Today’s date *
First Client Signature*
Second Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Information

I hereby acknowledge that I have been thoroughly informed about the proposed treatment, including its potential benefits, risks, and any contra-indications relevant to my medical condition. I understand that there are inherent risks associated with the procedure, including but not limited to temporary discomfort or pain, bruising or redness, nerve irritation. Despite these potential risks, I hereby voluntarily consent to undergo the proposed treatment. I understand that I have the right to ask questions and seek further clarification at any stage. By signing below, I acknowledge that I am providing my informed consent for the treatment.

Today’s date *
Third Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Information

I hereby acknowledge that I have been thoroughly informed about the proposed treatment, including its potential benefits, risks, and any contra-indications relevant to my medical condition. I understand that there are inherent risks associated with the procedure, including but not limited to temporary discomfort or pain, bruising or redness, nerve irritation. Despite these potential risks, I hereby voluntarily consent to undergo the proposed treatment. I understand that I have the right to ask questions and seek further clarification at any stage. By signing below, I acknowledge that I am providing my informed consent for the treatment.

Today’s date *
Fourth Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Information

I hereby acknowledge that I have been thoroughly informed about the proposed treatment, including its potential benefits, risks, and any contra-indications relevant to my medical condition. I understand that there are inherent risks associated with the procedure, including but not limited to temporary discomfort or pain, bruising or redness, nerve irritation. Despite these potential risks, I hereby voluntarily consent to undergo the proposed treatment. I understand that I have the right to ask questions and seek further clarification at any stage. By signing below, I acknowledge that I am providing my informed consent for the treatment.

Today’s date *
Fifth Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Information

I hereby acknowledge that I have been thoroughly informed about the proposed treatment, including its potential benefits, risks, and any contra-indications relevant to my medical condition. I understand that there are inherent risks associated with the procedure, including but not limited to temporary discomfort or pain, bruising or redness, nerve irritation. Despite these potential risks, I hereby voluntarily consent to undergo the proposed treatment. I understand that I have the right to ask questions and seek further clarification at any stage. By signing below, I acknowledge that I am providing my informed consent for the treatment.

Today’s date *
Sixth Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Information

I hereby acknowledge that I have been thoroughly informed about the proposed treatment, including its potential benefits, risks, and any contra-indications relevant to my medical condition. I understand that there are inherent risks associated with the procedure, including but not limited to temporary discomfort or pain, bruising or redness, nerve irritation. Despite these potential risks, I hereby voluntarily consent to undergo the proposed treatment. I understand that I have the right to ask questions and seek further clarification at any stage. By signing below, I acknowledge that I am providing my informed consent for the treatment.

Today’s date *
Seventh Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Information

I hereby acknowledge that I have been thoroughly informed about the proposed treatment, including its potential benefits, risks, and any contra-indications relevant to my medical condition. I understand that there are inherent risks associated with the procedure, including but not limited to temporary discomfort or pain, bruising or redness, nerve irritation. Despite these potential risks, I hereby voluntarily consent to undergo the proposed treatment. I understand that I have the right to ask questions and seek further clarification at any stage. By signing below, I acknowledge that I am providing my informed consent for the treatment.

Today’s date *
Eighth Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Information

I hereby acknowledge that I have been thoroughly informed about the proposed treatment, including its potential benefits, risks, and any contra-indications relevant to my medical condition. I understand that there are inherent risks associated with the procedure, including but not limited to temporary discomfort or pain, bruising or redness, nerve irritation. Despite these potential risks, I hereby voluntarily consent to undergo the proposed treatment. I understand that I have the right to ask questions and seek further clarification at any stage. By signing below, I acknowledge that I am providing my informed consent for the treatment.

Today’s date *
Ninth Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Information

I hereby acknowledge that I have been thoroughly informed about the proposed treatment, including its potential benefits, risks, and any contra-indications relevant to my medical condition. I understand that there are inherent risks associated with the procedure, including but not limited to temporary discomfort or pain, bruising or redness, nerve irritation. Despite these potential risks, I hereby voluntarily consent to undergo the proposed treatment. I understand that I have the right to ask questions and seek further clarification at any stage. By signing below, I acknowledge that I am providing my informed consent for the treatment.

Today’s date *
Tenth Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Information

I hereby acknowledge that I have been thoroughly informed about the proposed treatment, including its potential benefits, risks, and any contra-indications relevant to my medical condition. I understand that there are inherent risks associated with the procedure, including but not limited to temporary discomfort or pain, bruising or redness, nerve irritation. Despite these potential risks, I hereby voluntarily consent to undergo the proposed treatment. I understand that I have the right to ask questions and seek further clarification at any stage. By signing below, I acknowledge that I am providing my informed consent for the treatment.

Today’s date *
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information

I hereby acknowledge that I have been thoroughly informed about the proposed treatment, including its potential benefits, risks, and any contra-indications relevant to my medical condition. I understand that there are inherent risks associated with the procedure, including but not limited to temporary discomfort or pain, bruising or redness, nerve irritation. Despite these potential risks, I hereby voluntarily consent to undergo the proposed treatment. I understand that I have the right to ask questions and seek further clarification at any stage. By signing below, I acknowledge that I am providing my informed consent for the treatment.

Today’s date *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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