HIFU Consultation Form

(Branch - Reading)

By completing this Client Profile, you will assist us in evaluating you and your specific concerns. The information you will provide will be used to determine what factors may be affecting you as that we may recommend the proper careText

First Name *

Last Name *

Date of birth (DD-MM-YYYY) *

Gender *

Male

Female

Other

Phone *

Email *

Address

Street Address *

City *

State *

Postal code *

How many hours do you sleep per night?

How often do you exercise?

On a scale of 1 (low) to 10 (high) how would you rate your stress levels?

Occupation?

Age of children? (if any)

Nutrition

Please indicate the frequency of these foods consumed on a weekly basis:

Sugar

Spicy Foods

Takeaways

Snack foods

Salty food

Fast foods

Please indicate the quantities of fluid consumed on a daily basis (cups or glasses):

Water

Juices

Coffee

Fizzy Drinks

Tea

Alcohol

Do you have any specific dietary requirements ?

Health/Medical

Doctor's name, address and phone number:

Other

Please list all medications that you have been prescribed by your GP:

Please list any non- prescriptive medication:

Health/Medical Cont

Have you ever had any surgery including cosmetic surgery (silicone implants)?

If yes, When?

Where on your body?

What information can you provide about the procedure?

Have you undergone treatment from a dermatologist/ skin peels/ botox /dermal filler/ threads/ IPL or laser?

If yes, When?

What type of treatment?

What information can you provide about the procedure?

Home Skin Care Regime

Describe in details (using product brand names ) exactly how you are presently caring for your skin

What are your concerns?

What is your specific concerns ?

Have you previously had High Intensity Focused Ultrasound treatments (please list other treatments received)?

What were the results?

What are your expectations of your chosen treatment ?

Client Release

POSSIBLE SIDE EFFECTS: Skin redness, skin sensitivity, numbness, heat reaction, blistering, headaches.

Absolute Contra-indications
Active Acne Pustules and Papules
Active Cancer patients and Cancer Treatment/History of Cancer
Anticoagulant Medication
Auto Immune Conditions/use of Immunosuppressive Medication
Diabetes
Epilepsy
Excessive Dryness
Fragile Skin
Heart Condition including Pacemaker
Hernia/Mesh (area specific)
Inflammation or Infection in the Treatment Area
Keloid Scarring
Liver and Kidney Malfunction
Metal Prosthesis or Implants (area specific)
Oral Steroid Medications
Pregnancy, Recent Pregnancy or Breast Feeding
Regular Anti Inflammatory Medication
Skin Thinning Medication
Thrombosis or Thrombophlebitis

Client declaration for High Intensity Focused Ultrasound on HIFU

I hereby authorise SHAPINS Clinic to treat me for HIFU. The limitations of
treatment and expected treatment outcome has been explained. I understand that a course of treatments are necessary with
regular maintenance treatments in the future to obtain optimal results.
The clinic above has informed me about alternative treatment possibilities and I understand that other forms of treatment or
no treatment at all, are choices that I have.
I agree to follow the pre- and post post treatment recommendations advised by the clinic above in order to ensure the best
possible results. I understand that excessive heat should be avoided for 48 hours and that significant exposure to the sun must
be avoided for at least two months after the treatment and a sunblock of SPF 30 or greater must be used on the exposed skin
areas. Failure to follow this advice may result in side effects such as blotchy skin and hyper- or hypo- pigmentation.
I have been informed of the possible side effects of treatment. I understand how and why these might occur and wish to
proceed with treatment and will not hold the clinic responsible should I suffer any of these side effects.
I agree to co-operate with the recommendations of the above clinic while I am under their care, realising that any lack of
co-operation could result in less than optimal results. I certify that all information the clinic has requested of me from
a medical/health nature is correct. It is my responsibility to inform the clinic should any of this information change.

I certify that I have read the entire informed consent and I agree to all of its provisions. I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure. I hereby give my consent and authorisation voluntarily and release the establishment and its agents of any claims that I have or may have in the future in connection with the described treatment.

I give consent for my photos to be used for marketing/ advertising purposes

Yes

Signature *

Clear

Our aim to provide incredible results in affordable prices.

Additional Comment