ULTRASOUND CAVITATION CONSENT FORM
ULTRASOUND CAVITATION TREATMENT AREA: (Please check all that apply)
Inner/ Outer Thighs
MEDICAL BACKROUND: (Check if you answer YES to any of these)
Are you pregnant or nursing?
Do you have any kind cancer?
Are you epileptic?
Do you have any cardiac or vascular problems?
Do you have a wound that has not healed?
Current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Abnormaly high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?
If you checked any of the above questions, please explain here
Current medications that you are taking
Are you taking any recreation drugs?
INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS
Pregnancy or nursing (current only).
Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.
Botox or filler in treatment area.
Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device.
Metal implants or other implants in the treatment area- ie. IUD, screws, plates.
Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.
Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of Immune suppressive medications.
Active weeping acne.
Continuous use of Retin A, retinol.
Medications such as blood thinners.
Skin blotches or rosacea.
Severe concurrent conditions such as cardiac disorders or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin.
Chemical sensitivities such as reactions to cosmetic products or perfumes.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.
If Chemical sensitivities was checked; If known, please list specific offending ingredients
Disqualifying Conditions for Multipolar Radio Frequency Treatments - Check off what applies to your condition
Implants: heart pace-maker, braces, cochlear, or any other artificial organ inside the body
Not feeling thermal changes
A burn or care after such a burn
Severe active arthritis
Severe cardiovascular disease, circulation troubles (thrombus arterial sclerosis, etc.)
Coagulation disorder or bleeding tendency
Acute hernia, discopathy, spondyloslysis
Migraines and Epilepsy
Acute infections or inflammations
Acutane and retinol
Botox or filler in treatment area
Suppuration of soft tissues
Any active condition in the treatment area, such as Herpes, sores, psoriasis, dermatitis, eczema and rash
Client Health History: Body Contouring, Cellulite Reduction, and/or Skin
Tightening Health History Intake
SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): *
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Areas of concern. Check all that apply: *
Upper Legs "Saddle Bags"
Lower Legs (Hamstring Area)
Arms (tricep side)
Flanks "Love Handles"
Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmenta- tion? Please List;
If yes, when?
What body area(s)?
Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions?
Pregnancy and/or breastfeeding
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillator, implanted neuro stimulators, or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
History of skin disorders
If yes, please list
If yes, please explain
Please list all vitamins and supplements including herbal remedies you take regularly *
Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly *
Is there anything else you would like us to know?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this his- tory. A current medical history is essential to execute appropriate treatment procedures. *