CLIENT INFORMATION & CONSENT FORM Hifu FormCLIENT INFORMATIONMEDICAL AND SURGICAL HISTORYHIFU CONSULT RECORDTERMS & CONDITIONSFirst NameEmailDateLast NamePreviousNext MEDICAL AND SURGICAL HISTORYAgeGender Male FemaleWeightHeightActive Wounds Yes NoActive severe or cystic facial acne Yes NoMetal stents in the treatment area Yes NoImplanted electrical devices Yes NoPregnant or lactating Yes NoMigraines Yes NoBell’s palsy Yes NoMechanical or other implants in the treatment area Yes NoActive or local skin disease that may alter wound healing* Yes NoAutoimmune disease Yes NoEpilepsy Yes NoHerpes or cold sores Yes NoHaemorrhagic or bleeding disorders Yes NoUndergone the following cosmetic procedure in the brow or lower face and neck area: Facial skin tightening procedure treatment within the last 1 year Yes NoIf Yes, please fill the below informationSome description about this sectionTreatment NameTreatment LocationDate of Last TreatmentFiller (i.e. juvederm® or Sculptra®) within the last 3-6months Yes NoIf Yes, please fill the below informationSome description about this sectionTreatment NameTreatment LocationDate of Last TreatmentNeurotoxin (i.e. Botox® or Dysport®) within the last 3-6months Yes NoIf Yes, please fill the below informationSome description about this sectionTreatment NameTreatment LocationDate of Last TreatmentAblative resurfacing laser treatment Yes NoIf Yes, please fill the below informationSome description about this sectionTreatment NameTreatment LocationDate of Last TreatmentNon-ablative resurfacing laser treatment Yes NoIf Yes, please fill the below informationSome description about this sectionTreatment NameTreatment LocationDate of Last TreatmentDermabrasion or deep facial peels Yes NoIf Yes, please fill the below informationSome description about this sectionTreatment NameTreatment LocationDate of Last TreatmentLipo-plasty in the face or neck regions Yes NoIf Yes, please fill the below informationSome description about this sectionTreatment NameTreatment LocationDate of Last TreatmentFacelift or blepharoplasty or brow lift Yes NoIf Yes, please fill the below informationSome description about this sectionTreatment NameTreatment LocationDate of Last TreatmentAre you currently taking the following prescription medications? Accutane within the last 12 months Anticoagulants or antiplatelet drugs Immunosuppressant drugsList all medications or supplements below. Be sure to include all prescription or nonprescription medications. If you are not taking any medications or supplements, please leave them blank:PreviousNextPlease select your age group 35 year 36-49 year 50-64 year 65+ yearHealth No health issues Minor health issues Chronic health issuesClinical response Factors None Mild Moderate SevereVolume None Mild Moderate SevereSmoking History please select Never smoked Ex-smoker Light smoker Heavy smokerSun Exposure Never use sunscreen Occasionally use sunscreen Always use sunscreenSkin Laxity None Mild Moderate SevereSkin Quality None Mild Moderate SeverePreviousNextTERMS & CONDITIONS It is important you read through the patient consent form and thoroughly understand it before you complete and submit the form. All questions are mandatory before the commencement of any Treatment, if there are any questions that are unanswered - you will not be able to continue. WHAT TO EXPECT DURING AND AFTER YOUR HIFU TREATMENT? You can expect to experience some discomfort as the ultrasound energy is delivered.Your Aesthetic Practitioner will agree a plan to optimise your comfort during theprocedure. HIFU treatment is efficient. For example, a treatment for the full face and neck will lastapproximately 90 minutes. POSSIBLE SIDE EFFECTS OF HIFU TREATMENT Your skin may appear red for a few hours after HIFU treatment. You may experience slight swelling, tingling or tenderness for a few days after treatment. Rarely, some people may experience temporary bruising welts or numbness. There is a slight risk of a burn to the skin, which may or may not lead to scarring. Both a burn and any scarring will respond to medical treatment Temporary nerve inflammation will resolve in a few days or weeks. If a motor nerve has become inflamed, you might experience some temporary localmuscle weakness. There could be some temporary numbness if a sensory nerve hasbecome inflamed. DECLARATION I have read and understood all the information provided and I have had the opportunity to ask any questions concerning the nature of the treatment, its expected results, and its possible risks and complications. It has been explained to me that the results of HIFU treatment can vary from person toperson. I am aware that occasionally the collagen that builds in the deep layers of theskin, providing support for the skin structure and helping to counter the effects of gravity, might not have a visible effect on the surface of the skin. I also understand that the results will be seen gradually over a period of 3 months and that some people will benefit from more than one treatment. I understand that HIFU treatment is a non-invasive treatment. It is not designed to produce the same results as an invasive surgical procedure. I have read the above and consent to receiving the treatment at my own discretion.PHOTOGRAPHCheckbox Field I authorise the taking of photographs and video footage which will be retained as a private record for the clinic and practitioner I ALSO CONSENT THE USE OF MY PHOTOGRAPHS AND VIDEO FOOTAGE FREE OF CHARGE FOR MARKETING PURPOSES.Signature Sign Here Date / TimeParentParentChildChildGrand ChildGrand Child Previous Submit Form