Urologix | CTT Form

Indications, contraindications, warnings, precautions and instructions for use can be found with the product labeling packaged with each device. Federal (U.S.A.) law restricts this device by or on the order of a physician trained and/or experienced in the use of this device. This treatment is contraindicated for patients with urethral stricture, peripheral arterial disease with intermittent claudication or Leriches Syndrome; and for patients who have undergone pelvic radiation therapy or have implanted active devices within 2.6 inches of the prostatic urethra. For more complete information about the benefits, risks and contraindications associated with this procedure please refer to the instructions for use packaged with each device.

Cooled ThermoTherapy is a trademark of Urologix, Inc. Prolieve is a trademark of Celsion Corporation. TherMatrx is a trademark of American Medical Systems. Coretherm is a trademark of Prostalund, Inc.
©2008 Urologix, Inc. All rights reserved. MC1454 Rev A 03/08

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Please complete this form so we can address your specific requests.

What microwave therapy are you currently using?

I am not currently offering microwave treatment for BPH but would like to
add this treatment to my office practice.

Please provide the following information:

Physician Name:

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Telephone:

Company:

Contact Name (Ex: Office Manager):

Street Address:

City: State: Zip Code:

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