Elitone’s Prescription Form
(aka Detailed Written Order – DWO)

Do NOT use if you:

• Are pregnant or attempting to become pregnant. The safety of electronic muscle stimulators during pregnancy has not been established.
• Have an electronic implant (e.g. cardiac pacemaker, implanted defibrillator) or suffer from heart problems.
• Have cancer, epilepsy, or cognitive dysfunction.
• Had pelvic floor surgery within the last six weeks.
• Have complete denervation of the pelvic floor.
• History or symptoms of urinary retention, extra-urethral incontinence, or overflow incontinence.

Consult your healthcare provider before using the device if:

• You have any serious illness or injury not mentioned in this guide.
• You have an underlying neurological condition (e.g. Multiple Sclerosis or Parkinson’s disease).
• You have a tendency to hemorrhage, following acute trauma or fracture.
• You take insulin for diabetes.
• You suffer from muscle or joint problems, including pelvic pain or a paravaginal defect.
• You suffer with suspected or diagnosed heart disease.
• You underwent a recent surgical procedure and where muscle contraction may disrupt the healing process.
• You have any doubt about using the device.