Could You Be a Candidate for Our Facial Wrinkle Study?

Please answer a few questions to help us determine whether you may be a potential candidate for our clinical research study evaluating a non-invasive ultrasound treatment for facial wrinkles.

This questionnaire is for preliminary screening only. Completing it does not guarantee eligibility or participation in the study.

Full Name *

Date of birth *

Phone *

Email *

Do you currently have visible facial wrinkles that you would be interested in treating?

Yes - CONTINUE

No - STOP

Are you willing to receive the study's non-invasive ultrasound treatment?

Yes - CONTINUE

No - STOP

Are you willing to avoid other cosmetic procedures in the treatment area throughout the study?

Yes - CONTINUE

No - STOP

Have you had any of the following treatments in the face or neck? Select all that apply.

Laser or IPL treatment within the past month

Radiofrequency treatment or face/neck lift surgery within the past 6 months

Botox or another neuromodulator within the past 6 months

Biodegradable dermal filler within the past 12 months

Facial liposuction, fat transfer or fat injections within the past 12 months

None of the above

Are you currently pregnant, breastfeeding, or planning to become pregnant during the study?

Yes - STOP

No - CONTINUE

Are you currently participating in another investigational drug or medical-device study, or have you recently received an investigational treatment in the area being treated?

Yes - REVIEW

No - CONTINUE

Maybe - REVIEW

Do you currently have any of the following in the proposed treatment area?

Open wounds or skin lesions

Active cold sores/herpes

Active, severe, or significantly inflamed acne

None of the above

Do you have a metal implant in the area that would be treated? Dental implants do not count.

Yes - STOP

No - CONTINUE

Not sure - REVIEW

Have you ever developed keloid or hypertrophic (raised/thick) scars?

Yes - STOP

No - CONTINUE

Not sure - REVIEW

Have you experienced severe multiple allergies or anaphylactic shock?

Yes - STOP

No - CONTINUE

Have you had cancer within the past 5 years?

Yes - STOP

No - CONTINUE

Do you have a history of facial or neck nerve paralysis?

Yes - STOP

No - CONTINUE

Are you planning to gain or lose 10 pounds or more during the study period?

Yes - STOP

No - CONTINUE

Do you currently smoke tobacco, or have you smoked tobacco within the past 12 months?

Yes - STOP

No - CONTINUE

Do you have a history of epileptic seizures?

Yes - STOP

No - CONTINUE

Do you have a history of severe migraines?

Yes - STOP

No - CONTINUE

Have you taken Accutane (isotretinoin) or another oral retinoid within the past 6 months?

Yes - STOP

No - CONTINUE