Extra-Corporeal Shockwave Therapy Form

Name*

First NameLast Name

* Please enter either a landline or mobile number below. This is required if we need to contact you about the information you provide on this form. Your private data will not be shared with any third party.

Your Mobile Number

Mobile phone number

Your Landline Number (unnecessary if mobile number provided)

Area CodePhone Number

Email

example@example.com

Date of Birth*

DayMonthYear

Who has recommended you for shockwave treatment?*

PhysiotherapistConsultantOther healthcare professionalSelf referral

Diagnosis and reason for treatment*

WHAT DOES ECSWT DO?

Extracorporeal shockwave therapy is a non-invasive treatment in which a device is used to pass acoustic shockwaves through the skin to the affected area, it can be utilised in the treatment of tendon and bone pathology.

The shockwaves stimulate the body’s own healing mechanisms to facilitate the repair of the damaged tendon and bone. A normal course of treatment will consist of three sessions with no more than a two-week gap between sessions. More sessions could be considered for chronic conditions.

ADVICE

Following ECSWT maintain ‘normal’ levels of activity. Do not do anything you normally would not do. Avoid sport, any other aggravating activities, or any activities, which stress the affected/treated area, particularly for the next 48 hours. Do not use ice on the treated area or take non-steroidal anti-inflammatory medicines (NSAIDS) e.g. ibuprofen, naproxen, as these may reduce the therapeutic effect of ECSWT.

WHAT ARE THE SIDE EFFECTS?

The practitioner providing the treatment will have checked your medical history to ensure that you are at minimal risk of any side effects.

Most Common:

Redness or bruising in the treated area.
Skin damage
An increase in pain in the treated area, this
can be controlled with paracetamol, please do
not take NSAIDs e.g. ibuprofen, naproxen.

Very Rare:

Tendon tear or rupture

Exclusion Criteria / Contraindications:

Steroid injection in the past 6 weeks
Tendency to haemorrhage/bleed
Haemophiliac patients
Patients taking anti-coagulant therapy such as warfarin or Apixiban (this may depend on exactly what you are taking – please contact us prior to booking)
Acute inflammation of the treatment area
Tumour at the treatment site
Infection of the treatment area
Pregnancy
Severe circulatory disorder
Nerve disorder at treatment site
Open wound at the treatment site
Prosthesis

PLEASE NOTE: At Complete Physio, we do not use shockwave therapy for:

Low back pain
Neck pain
Sciatica

We advise that anti-inflammatory medications, such as Ibuprofen and Naproxen, are stopped 48 hours before you commence shockwave treatment and are not used during the entire shockwave treatment period.

Pre-cautions: - Cardiac problems - Circulatory problems

If you would like to discuss any of this information before booking, then please do not hesitate to email us at info@complete-physio.co.uk and one of our senior therapists will contact you.

Signature (To draw your signature: Place the mouse cursor in the area below, click and hold the left mouse button then move the mouse as if you were drawing) *

I confirm I understand the information above and I have been given the opportunity to ask any questions. I understand what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns. I agree to the procedure or course of treatment described on this form.*

Accept

Once we receive the completed form, this will then be screened by one of our senior clinicians. Once approved, one of our booking team will contact you to get you booked for an appointment – please note we aim to screen all consent forms within a maximum of 1-2 working days.

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