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. Patient's name Date Active wounds*YesNo Mechanical or other implants in the treatment area**YesNo Active severe or cystic facial acne*YesNo Active or local skin disease that may alter wound healing***YesNo Metal stents in the treatment area**YesNo Autoimmune disease***YesNo Implanted electrical devices**YesNo Epilepsy***YesNo Pregnant or lactating***YesNo Herpes or cold sores***YesNo Migraines***YesNo Diabetes***YesNo Bell’s palsyYesNo Hemorrhagic or bleeding disorders***YesNo List any chronic illness: Undergone the following cosmetic procedure in the brow or lower face and neck area: (i) Facial skin tightening procedure treatment within the last 1year YN Treatment name: Location treated: Date of last treatment: (ii) Filler (i.e. juvederm® or Sculptra®) within the last 3-6months YN Treatment name: Location treated: Date of last treatment: (iii) Neurotoxin (i.e. Botox® or Dysport®) within the last 3-6months YN Treatment name: Location treated: Date of last treatment: (iv) Ablative resurfacing laser treatment YN Treatment name: Location treated: Date of last treatment: (v) Non-ablative resurfacing laser treatment YN Treatment name: Location treated: Date of last treatment: (vi) Dermabrasion or deep facial peels 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 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 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 Date Reason for Contact *Value1Value2 Area of Interest *Value1Value2 submit