eConsent form

    Patient Name

    Date

    Email

    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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