Hifu Consultation - Form Laserology Bali

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Last Name

Date

TERMS & 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 the
procedure.
HIFU treatment is efficient. For example, a treatment for the full face and neck will last
approximately 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 local
muscle weakness. There could be some temporary numbness if a sensory nerve has
become 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 to
person. I am aware that occasionally the collagen that builds in the deep layers of the
skin, 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.

PHOTOGRAPH

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.

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Date / Time

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CLIENT INFORMATION & CONSENT FORM

MEDICAL AND SURGICAL HISTORY

TERMS & CONDITIONS

PHOTOGRAPH