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High Intensity Focused Ultrasound

It is important that you read the material provided and understand the expected outcomes and possible risks of HIFU treatment. Please ensure that you ask any questions you might have.

This consent form must be signed for treatment to proceed.

During HIFU treatment, low amounts of Micro-Focused Ultrasound energy are delivered into precise skin depths, without damaging the surface of the skin. The HIFU energy creates heat, which stimulates tissue remodelling. The result, over time, is a natural skin lifting, tightening and rejuvenation.

WHAT TO EXPECT DURING AND AFTER YOUR ULTRASOUND TREATMENT

• You can expect to experience some mild to moderate discomfort as the ultrasound energy is delivered. Your 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 20-30 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 patients may experience temporary bruising welts or numbness.

• There is a slight risk of a burn to the skin, which will respond to medical treatment.

• Temporary nerve inflammation will resolve in a few days.

• If a motor nerve has become inflamed, you might experience some temporary local weakness. There could be some temporary numbness if a sensory nerve has become inflamed.

Do you feel sufficient information has been provided to you, to enable you to consent? *

Yes

Has your consent been freely given? *

Yes

Are you pregnant or breastfeeding? *

Yes

Do you have muscular disorders (myasthenia gravis, Lambert-Eatonn syndrome, etc.)? *

Yes

Do you have a pacemaker or any neuromodulators?

Yes

Do you have history of Chemotherapy? *

Yes

Do you have an infection or inflammation in the treatment site? *

Yes

Do you have an autoimmune disease? *

Yes

Do you have any medical conditions? *

Yes

If yes, what are they?

Do you have any metal plates in your face or jaw?

Yes

Do you have any known allergies or have ever had anaphylaxis?

Yes

If yes, what are they?

Do you have any active infection at the intended site of procedure? *

I Understand

Are you taking antibiotics or other prescription medications? *

Yes

If yes, what are they?

Is there any other Medical and/or Social History that we should know? If so, please provide full detail here.

What are your aims/motivations for having the procedure and the desired outcome? Please provide full details here.

Have you had this or a similar treatment before? If so, did you experience any problems? Please provide full details here.

Do you have any concerns? If so, please provide full details here.

Is there anything else we should know? Please provide full details here.

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 patient to patient. 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 to 6 months, and that some patients 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. *

Yes Have read and Understood

The following points of information have been specifically discussed and I have had the opportunity to ask any questions concerning this information:

The HIFU System delivers a low amount of focused ultrasound energy to the skin. The heat from the ultrasound stimulates new collagen to form. I understand that there can be discomfort during the treatment when the ultrasound energy is delivered. I have discussed with my practitioner the options available to me to optimize my comfort during the procedure.

Immediately following HIFU the skin may appear red for a few hours. It is not uncommon to experience slight swelling for a few days following the procedure or tingling/tenderness to the touch for days to weeks following the procedure, but these are mild and temporary in nature.

Occasional temporary effects may include bruising or welts, which resolve in hours to days, or numbness in a select area, which resolves in days to weeks.

I can attest that I am not Type 1 Diabetic, Pregnant, Breast Feeding, Epileptic or have any implanted metallic devices insitu.

As with any medical procedure, there are possible risks associated with the treatment. There is a remote risk of a burn that may or may not lead to scarring (either of which will respond to medical care), or temporary nerve inflammation, which will resolve in a matter of days to weeks.

It has been explained to me that the results vary from patient to patient, and, occasionally, the collagen building on the inside that helps counter the effects of gravity does not have a visible effect on the outside. I understand that results will unfold over the course of 3 to 6 months and that some patients may benefit from more than one treatment.

I also understand that a non-invasive HIFUtreatment is not intended to produce the same results as an invasive surgical procedure.

PHOTOGRAPHS I authorise the taking of photographs and video footage which will be retained as a private record for the clinic and practitioner.

Yes

I will retain this information throughout the course of my treatment and refer to it as required. *

Yes

I accept that all deposit are non-refundable? *

Yes

Patient Signature

Clear

HIFU Face & Neck non Surgical Face Lift

Nur Aesthetics Clinic Ltd

High Intensity Focused Ultrasound

WHAT TO EXPECT DURING AND AFTER YOUR ULTRASOUND TREATMENT

POSSIBLE SIDE EFFECTS OF HIFU TREATMENT