Men’s Health Physiotherapy

(Patient Consent Form

Thank you for choosing to attend a Men’s Health Physiotherapy appointment with The Fernandes Clinic. Please complete the personal details below and read the information before signing to confirm your understanding and consent.

Personal Details

Prefix

First name

Last name

Date of Birth

Day

Month

Year

Address

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 Contact Number

Email

Next of Kin

Prefix

First name

Last name

Contact Number

Biological Sex (for clinical relevance) - What is your biological sex (as assigned at birth)?

Male

Female

Intersex

Prefer not to say

Health Administration

Referrer (if applicable)

Are you referring yourself or have you been recommended by GP or medical consultant?

Self

G.P.

Medical Consultant

What is your main concern or reason for attending?

Have you had surgery or medical treatment in relation to this problem – please provide details below:

Past medical history

Current medications taken

What to Expect During Your Appointment

The following is designed to allow a thorough and holistic assessment so your therapist can develop a personalised treatment plan, based on your goals and agreed next steps.

Please tick each checkbox below to confirm that you provide consent.

Your Men’s Health Physiotherapy session will typically involve:

A detailed conversation to explore your medical history, current concerns, lifestyle factors, and goals.

A physical assessment, which may involve checking your breathing, posture, movement, abdominal and pelvic muscle function using external techniques.

Treatment, which may include education, tailored exercises, breathing techniques, manual therapy, and pelvic floor muscle training.

Common Conditions Treated in Men’s Health Physiotherapy Include:

Urinary leakage (incontinence)
Erectile difficulties or changes in sexual function
Pelvic floor dysfunction (weak or overactive muscles)
Pelvic pain or discomfort
Nerve-related pain in the pelvic region (e.g. pudendal nerve sensitivity)
Painful urination
Urine leakage at orgasm (climacturia)
Difficulty getting or maintaining a firm erection (hard-flaccid syndrome)
Before and after prostate surgery (e.g. prostatectomy rehab)
Bowel issues, including faecal incontinence or constipation
Changes in penile shape or discomfort due to scar tissue (e.g. Peyronie’s disease)
Groin or pubic joint pain (osteitis pubis)

Your Comfort and Privacy

You will remain fully dressed throughout the session, though we may ask you to adjust your clothing slightly to allow for observation of posture, breathing, or pelvic position.
No internal (rectal) examinations will be performed.
You are welcome to bring a chaperone with you if you feel more comfortable.
You can withdraw consent or pause the session at any time.

I have read and understood the potential side effects and risk associated with the treatment.

Accept

Consent Declaration

I confirm that I have read and understood the information above. I consent to take part in the Men’s Health Physiotherapy assessment and treatment as outlined, and I understand that I can ask questions or withdraw at any time.

Date

Signature*

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Extra-Corporeal Shockwave Therapy

(ECSWT) Consent Form

Patient Information

First name

Last 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 Contact Number

Email

Date of Birth

Day

Month

Year

Who has recommended you for shockwave treatment?

Physiotherapist

Consultant

Other healthcare professional

Self 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 The Fernandes Clinic, 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@thefernandesclinic.com and one of our therapists will contact you.

Please confirm that you accept our Terms & Conditions. Important information - Please read.

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. Alternatively, upload your signature.

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I confirm that I understand the information above, have had the chance to ask questions, and understand the procedure, its benefits, risks, and alternatives (including no treatment). I agree to the procedure or treatment described.

Accept

Once we receive the completed form, this will then be screened by one of our 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.

Consent Forms

Access all necessary consent forms and provide your approval securely before your visit.

Read before continuing

Select your appropriate consent form below:

Men’s Health Physiotherapy

(Patient Consent Form

Personal Details

Next of Kin

Health Administration

What to Expect During Your Appointment

Signature*

Patient Consent Form

For home visit physiotherapy

Next of Kin

Signature*

Extra-Corporeal Shockwave Therapy

(ECSWT) Consent Form

Patient Information

Signature*

Patient Consent Form

For paediatric physiotherapy

Patient's Information

Patient's details

Clinic location

Signature*

Parent/Legal Guardian Consent Form

For paediatric physiotherapy

Patient's Information

Parent/Legal Guardian Information

Signature*