eConsent form

Patient Name

Date

Medical and Surgical History

Age:

Weight :

Height:

Gender

Active wounds*

Active severe or cystic facial acne*

Metal stents in the treatment area*

Implanted electrical devices*

Pregnant or lactating

Migraines

Bell’s palsy

Mechanical or other implants in the treatment area*

Active or local skin disease that may alter wound healing*

Autoimmune disease*

Epilepsy*

Herpes or cold sores*

Diabetes*

Hemorrhagic or bleeding disorders*


Undergone the following cosmetic procedure in the brow or lower face and neck area: Facial skin tightening procedure treatment within the last 1year

If Yes, Please fill the below information

Treatment name

Location treated:

Date of last treatment


Filler (i.e. juvederm® or Sculptra®) within the last 3-6months

If Yes, Please fill the below information

Product name

Location treated:

Date of last treatment


Neurotoxin (i.e. Botox® or Dysport®) within the last 3-6months

If Yes, Please fill the below information

Product name

Location treated:

Date of last treatment


Ablative resurfacing laser treatment

If Yes, Please fill the below information

Treatment name

Location treated:

Date of last treatment


Non-ablative resurfacing laser treatment

If Yes, Please fill the below information

Treatment name

Location treated:

Date of last treatment


Dermabrasion or deep facial peels

If Yes, Please fill the below information

Treatment name

Location treated:

Date of last treatment


Lipoplasty in the face or neck regions

If Yes, Please fill the below information

Treatment name

Location treated:

Date of last treatment


Facelift or blepharoplasty or brow lift

If Yes, Please fill the below information

Treatment name

Location treated:

Date of last treatment

Are you currently taking the following prescription medications:

Accutane within the last 12 months

Anticoagulants or antiplatelet drugs

Immunosuppressant drugs


List all medications or supplements below. Be sure to include all prescription or non-prescription medications. If you are not taking any medications or supplements, please leave them blank:

Medication

Disease/Reason

Dose

Frequency

Date started

Date last taken


HIFU CONSULT RECORD

Every patient is different, the clinical factors listed below are intended to assist your clinician in forecasting your clinical response to HIFU treatment. Please score each clinical factor listed below. Upon examination of your responses, your physician will discuss your options for achieving optimum results with HIFU treatment.

Age

<35 y/o35-49 y/o50-64 y/o65+ y/o

Smoking History

Never smokedEx-smokerLight smokerHeavy smoker

Health

No health issuesMinor health issuesChronic health issues

Sun exposure

Never use sunscreenOccasionally use sunscreenAlways use sunscreen


Clinical response Factors- Upper face and neck: Check the appropriate box
None
Mild
Moderate
Severe
Skin Laxity:
Excess skin or hooding on the eyelid; eye droopiness
Volume:
Presence of fat deposits under eyes; infra-orbital puffiness
Skin Quality:
Fine lines, creepiness/wrinkling, and/or poor elasticity

Clinical response Factors- Lower face and neck: Check the appropriate box
None
Mild
Moderate
Severe
Volume:
Presence of fat deposits under eyes; infra-orbital puffiness
Skin Quality:
Fine lines, creepiness/wrinkling, and/or poor elasticity

Clinical response Factors- Body: Check the appropriate box
None
Mild
Moderate
Severe
Volume:
Presence of fat deposits under eyes; infra-orbital puffiness
Skin Quality:
Fine lines, creepiness/wrinkling, and/or poor elasticity

What are your treatment Goals

Additional findings:


Patient Signature

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