Patient’s Consent Form

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
    Active wounds*YesNo
    Active severe or cystic facial acne*YesNo
    Metal stents in the treatment area**YesNo
    Implanted electrical devices**YesNo
    Pregnant or lactating***YesNo
    Migraines***YesNo
    Bell’s palsyYesNo

    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

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