Once you have completed this form and confirmed you have no contraindications to using the PelviPower chair, you can go ahead and book your free trial.

FAQ about the screening form

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PelviPower Screening, Information Gathering, Understanding, & Consent Form

First name

Last name

Email

Phone

Birthday

Day

Month

Year

SREENING

PelviPower Contraindication Check

Please read each point carefully and select Yes or No.

If you select Yes for any item, the PelviPower chair is NOT suitable for you at this time, and we will discuss alternative options to support you.
If you select No, you are confirming that the item does not apply to you and agree that the PelviPower chair is a safe and appropriate treatment method for you.

Please confirm your biological gender.

Female

Male

(For females, this then opens up a few more specific questions for you)

Do you have METAL in your spine, pelvis, hips, or upper leg?

Yes

No

Do you have a bladder pacemaker, cardiac pacemaker, or any implanted electronic device?

Yes

No

Do you use an insulin pump?

Yes

No

Do you have an implanted defibrillator?

Yes

No

Do you have a neurostimulator?

Yes

No

Do you have decompensated heart disease or irregular heart rhythms/arrhythmias, or any unmanaged or unstable heart conditions?

Yes

No

Do you have epilepsy?

Yes

No

Do you currently have active cancer, are you undergoing investigation or treatment for cancer, or are you currently being monitored or treated for pre-cancerous cells (including skin cancer)?

Yes

No

Do you have any old tattoos (typically from the 1960s–1970s) on your lower torso, pelvic area or upper thigh?

Yes

No

Do you have any piercings or metal jewellery or metal underwear in the pelvic or genital area — that you cannot remove for all your PelviPower sessions?

Yes

No

Have you had recent surgery (< 6 weeks)?

Yes

No

Have you had pelvic surgery that included metal mesh or tape?

Yes

No

Do you have cochlear implants?

Yes

No

Do you wear hearing aids — that you CANNOT REMOVE during your PelviPower sessions?

Yes

No

Do you take blood-thinning medication?

Yes

No

Do you have an acute urinary tract infection (UTI)?

Yes

No

Do you currently have PAINFUL haemorrhoids?

Yes

No

Do you currently have an infection with a fever?

Yes

No

Any additional information that you would like to share?

Final confirmation for contraindications. Do any of the above contraindications apply to you?

Yes

No

If you select Yes, PelviPower chair is NOT suitable for you at this time.

If you select No, you are confirming that none of the contraindications apply to you, and agree the PelviPower chair is suitable for you.

INFORMATION GATHERING

Have you used PelviPower before?

Yes

No

What is your number one goal?

Please only list one thing.

Example:

"Stop leaking when walking the dog"

"Stop leaking when sneezing & coughing"

"Feel strong for my skiing holiday"

"Reduce my back pain"

"Reduce my pelvic pain"

"Improve my prolapse symptoms"

"Less trips to the toilet"

"Sport- injury prevention"

Any bonus goals you would like us to be mindful of?

Here you can list the other things that matter to you/that you can work on whilst addressing your number one goal.

What have you used/done/taken to help with your symptoms up to now?

Physio?

Medication?

Nothing?

?

Anything else you think would be good for us to know?

UNDERSTANDING

Please tick each statement to confirm your understanding:

Eligibility

I understand that I can only use PelviPower if I have no contraindications.

What PelviPower Is

I understand that PelviPower is a muscle training programme designed to improve pelvic floor function, coordination, and strength, as well as my core and deep hip stabilisers. It may also help release tight muscles. Like all physical training, results build gradually over time and rely on consistency, appropriate intensity, and listening to my body.

Training Frequency

I understand that muscles adapt through regular training. I may be advised to use PelviPower once, twice, or up to three times per week, depending on my needs. Optimal frequency varies from person to person.

Rest & Recovery

I understand that I should allow at least one rest day between sessions to support recovery and effective progress.

Function Along With Strength

I understand the importance of building function along with strength, including coordination, control, and the ability to both activate and relax my pelvic floor. Some pelvic floor issues are related to function rather than strength, and both are important for long-term improvement.

Programme Options

I understand that PelviPower at Harris Mind & Body offers programmes across six main training areas, and that the HMB team will guide me to the most appropriate starting point and pathway based on my individual needs.

Incontinence
Women’s Health
Men’s Health
Back
Release
Fitness

Programme Reviews

I understand that if I would like a review of my PelviPower programme, I can book a Programme Review at any time. These reviews provide dedicated time to check progress, adjust settings, and ask questions. Programme reviews are optional, bookable as needed, and carry an additional cost.

Electronic Devices & Personal Items

I understand and will remove and place personal items such as phones, smart watches, smart rings, earphones, keys, wallets, and cards at least 0.5 metres away from the PelviPower chair during use, as the electromagnetic field may interfere with or damage electronic devices.

External Metal (Clothing & Jewellery)

I understand that small amounts of external metal (such as clothing buttons, zips, underwire bras, or dental braces) are safe and/or outside the PelviPower chair’s field of activity. BUT metal items worn directly within the seated treatment area (for example, metal in underwear in direct contact with the chair & sensitive skin) are not suitable and should be avoided.

CONSENT

Informed Consent for PelviPower Training

Please tick each box to confirm your understanding and consent:

Contraindications

I confirm that I have completed the Contraindication Checks honestly and to the best of my knowledge, and I understand that PelviPower is not suitable for me if any contraindications apply.

Understanding the Training

I understand that PelviPower uses electromagnetic stimulation delivered through a seated chair to activate and train the pelvic floor, deep core, and hip stabilising muscles while I remain fully clothed.

Sensations & Effects

I understand that PelviPower is a safe muscle training method and that, like any form of physical training, it may cause temporary sensations such as warmth, muscle engagement, mild tenderness, or a post-exercise feeling.

Complementary Method

I understand that PelviPower is a complementary training method and does not replace medical diagnosis, investigation, or treatment by a doctor, specialist, or therapist.

Ongoing Medical Responsibility

I understand that I remain responsible for seeking medical advice, investigation, or treatment from my GP, physio, or healthcare professional for any symptoms, concerns, or changes in my health.

Changes in Health

I agree to inform Harris Mind & Body (HMB) in writing if my health changes in a way that may affect the suitability or safety of PelviPower training.

Voluntary Participation

I understand what PelviPower training involves and am happy to proceed.

Consent to Data Processing (GDPR)

I consent to Harris Mind & Body securely storing and processing my personal information for the purposes of administering PelviPower training, contacting me about my sessions, and ensuring my safety.

I confirm that the information I have provided is accurate and that I give my informed consent. Please sign here:

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Today's Date

What happens now:

How to book your FREE TRIAL session:

We will call you to arrange your booking once your screening form lands in our inbox.
We will email you to arrange your booking once your screening form lands in our inbox.
Chat to us in the clinic
You can call us on 01635 44882 — great if you are super keen to book something asap.
You can email us (details below).

FAQ / Extra Information to Support Your PelviPower Screening Form

This page is designed to help you understand some of the screening questions you are asked before using the PelviPower chair.

If anything here feels unclear or you’re unsure how it applies to you, please speak to us or check with your GP before proceeding.

Pregnancy & Trying to Conceive

PelviPower uses electromagnetic stimulation and is not suitable during pregnancy or if you are actively trying to conceive.

Coil / IUD

PelviPower can usually be used by individuals with an IUD/coil. However, as it uses electromagnetic stimulation, we cannot guarantee that the position of the IUD will remain unchanged. In rare cases, this could affect contraceptive effectiveness.

If you rely on an IUD for contraception, we recommend:

Using additional contraception during PelviPower training, and
Having your IUD checked by your GP or practice nurse before relying on it again.

Metal Inside the Body

We are concerned about metal inside the body and within the PelviPower chair’s seated treatment area.

Examples include:

Spinal or hip implants
Knee replacements within 10 cm above the knee (most knee replacements are fine, as they do not sit this high)
Metal clips, screws, rods, or wires in the pelvis or spine

If you are unsure whether your implant falls within the treatment area, please check with us or your GP.

Electronic Implants & Devices

PelviPower may interfere with electronic implants or devices, including:

Cardiac pacemakers or defibrillators
Neurostimulators
Insulin or medication pumps
Cochlear implants (some models require medical clearance)

If you have any implanted electronic device, the PelviPower chair is not suitable for you.

Heart Conditions

The stimulation may place additional demand on the cardiovascular system and could interfere with unstable heart rhythm control. PelviPower should only be considered once a heart condition is stable and appropriately managed. Well-managed heart conditions are generally suitable. If unsure, please check with your GP.

Epilepsy

Magnetic stimulation may increase seizure risk. If you have epilepsy, PelviPower is not recommended unless you have been medically cleared.

Cancer & Pre-Cancerous Conditions

PelviPower increases circulation and cellular activity. As a precaution, and because large-scale medical trials are not possible in this area, there is currently insufficient evidence to confirm the safety of electromagnetic stimulation for individuals with:

Active cancer
Recent cancer treatment
Current pre-cancerous conditions
Ongoing cancer investigation

This applies to all cancer types, including skin cancers.

If you have previously had cancer or pre-cancerous cells and have been medically discharged from care, PelviPower is generally considered suitable. As a general guideline, being medically cleared and out of follow-up for 5 years is commonly regarded as the gold standard for no longer being within a monitoring period. If unsure, please check with your GP before proceeding.

Tattoos

We are only concerned about tattoos within the seated treatment area, and only very old tattoos (typically from the 1960s–1970s, often done outside the UK). Older inks sometimes contained heavy metals (such as lead), which may react to magnetic fields. Modern, regulated tattoos are absolutely fine and are not a contraindication.

External Metal (Clothing & Jewellery)

Metal jewellery, piercings, and menstrual underwear containing metal fibres must be removed before treatment, as metal can warm slightly during magnetic stimulation and this is the main area of activity. Small amounts of metal elsewhere (such as buttons, zips, underwire bras, or dental braces) are generally fine, as they sit outside the field of activity.

Recent Surgery

Your body needs time to heal before using PelviPower safely. Recent surgery may mean PelviPower is temporarily unsuitable.

Mesh / Tape Surgery

Healing tissues and surgical materials can be affected by magnetic stimulation, particularly if any part contains metal. Most modern mesh and tape procedures use synthetic (non-metal) materials, which are fine once fully healed. If you are unsure what material was used or whether healing is complete, please check with your GP.

Hearing Aids

Hearing aids should be removed during treatment due to the magnetic field. If you can remove them, please do so and leave them on the table away from the chair during your session.

Blood-Thinning Medication

This question refers to prescribed blood-thinning or anticoagulant medication (for example, warfarin, apixaban, rivaroxaban, dabigatran, or similar). Most people taking blood-thinning medication can use PelviPower safely. However, increased circulation may increase the risk of bruising or tenderness for some individuals. Please check with your GP before proceeding.

Urinary Tract Infection (UTI)

PelviPower should not be used if you currently have a UTI. The stimulation can increase pelvic floor activity and local blood flow, which may worsen irritation or discomfort. Treatment should resume only once the infection has fully cleared.

Painful Haemorrhoids

PelviPower should not be used if you have painful haemorrhoids, as sitting on the chair and muscle stimulation can increase pressure and blood flow in the area. Please wait until symptoms have settled before resuming treatment.

Fever or Acute Illness

If you have a fever or are feeling unwell, your body needs rest. PelviPower is not recommended until you are fever-free and feeling better.

Once you have completed this form and confirmed you have no contraindications to using the PelviPower chair, you can go ahead and book your free trial.

PelviPower Screening, Information Gathering, Understanding, & Consent Form

SREENING

PelviPower Contraindication Check

Please read each point carefully and select Yes or No.

INFORMATION GATHERING

UNDERSTANDING

CONSENT

Informed Consent for PelviPower Training

Book my FREE PelviPower Trial

Pregnancy & Trying to Conceive

Coil / IUD

Metal Inside the Body

Electronic Implants & Devices

Heart Conditions

Epilepsy

Cancer & Pre-Cancerous Conditions

Tattoos

External Metal (Clothing & Jewellery)

Recent Surgery

Mesh / Tape Surgery

Hearing Aids

Blood-Thinning Medication

Urinary Tract Infection (UTI)

Painful Haemorrhoids

Fever or Acute Illness