PATIENT CONSENT FORM
HIFU TREATMENT SHOULD ONLY BE PERFORMED AFTER A COMPLETE DISCUSSION OF THE RISKS RELATED TO THE TREATMENT AND WRITTEN INFORMED CONSENT OBTAINED.
Treatment name:
Location treated:
Date of last treatment:
(ii) Filler (i.e. juvederm® or Sculptra®) within the last 3-6months
YN
YN
Treatment name:
Location treated:
Date of last treatment:
(iii) Neurotoxin (i.e. Botox® or Dysport®) within the last 3-6months
YN
YN
Treatment name:
Location treated:
Date of last treatment:
(iv) Ablative resurfacing laser treatment
YN
YN
Treatment name:
Location treated:
Date of last treatment:
(v) Non-ablative resurfacing laser treatment
YN
YN
Treatment name:
Location treated:
Date of last treatment:
(vi) Dermabrasion or deep facial peels
YN
YN
Treatment name:
Location treated:
Date of last treatment:
(vii) Lipoplasty in the face or neck regions radio radio-256 label_first default:1 "Y" "N"]
Treatment name:
Location treated:
Date of last treatment:
(viii) Facelift or blepharoplasty or brow lift
YN
YN
Treatment name:
Location treated:
Date of last treatment:
Are you currently taking the following prescription medications:
1. Accutane within the last 12 months:
2. Anticoagulants or anti-platelet drugs:
3. 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 check here: Not any
Age <35 y/o35-49y/o50-64y/o65+y/o
Smoking History Never smokedEx-smokerLight smokerHeavy
Health No health issuesMinor health issuesChronic health issues
Sun exposureNever use sunscreenOccasionally use sunscreenAlways use sunscreen
Smoking History Never smokedEx-smokerLight smokerHeavy
Health No health issuesMinor health issuesChronic health issues
Sun exposureNever use sunscreenOccasionally use sunscreenAlways use sunscreen
Age <35 y/o35-49y/o50-64y/o65+y/o
Smoking History Never smokedEx-smokerLight smokerHeavy
Health No health issuesMinor health issuesChronic health issues
Sun exposureNever use sunscreenOccasionally use sunscreenAlways use sunscreen
Smoking History Never smokedEx-smokerLight smokerHeavy
Health No health issuesMinor health issuesChronic health issues
Sun exposureNever use sunscreenOccasionally use sunscreenAlways use sunscreen
Date