HIFU Consent Form

HIFU CONSULTATION AND CONSENT FORM

Please answer the consultation questions appropriately. This questionnaire will guide us for your upcoming treatment.

Full Name *

Phone *

Email *

Date of birth *

Medical History

Do you have any allergies? If yes, please specify: *

Are you currently taking any medication? *

Yes

Do you have any history of skin diseases, disorders, or issues? If yes, please specify: *

Are you currently pregnant or nursing? *

Yes

Do you have a history of keloid scarring? *

Yes

Consent and Acknowledgment

RISK: Even though the risk of complication is extremely low, the following can occur:

crusting, itching pain, bruising, dry skin, hyperpigmentation, hypopigmentation, pimple-like bumps, blistering, burns, infection, scabbing, swelling, small risks of scarring and failure to achieve desired results.
Understanding the sensation of the high treatment can feel like pins and needles, lasting up to 5 hours.
Can result in transient/permanent numbness, nerve damage or tingling sensation.
short term effects can include mild swelling, erythema, mild burning, temporary bruising and can be resolved within 1-3 months.
Delayed or allergic inflammatory reactions can occur.
I am 18 years or over.
I understand that there is no refund for any of the services performed.I am fully aware that this procedure is made voluntarily, and I have had the opportunity to ask questions and have them answered to my satisfaction.
I have been informed about the aftercare instructions and commit to following them diligently.
I release the practitioner and the establishment from liability if any complications or unfavourable results arise from the treatment.
I understand the costs associated with this procedure and accept full responsibility for these costs.
I certify that I have voluntarily sought the services provided and consent to the treatment.

Signature *

By signing and ticking this, I have read and agree to the clinic procedures of the treatment(s) that I have availed and abide from the instructions.