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Ultherapy Consent Form
 

Please fill out the following form
in order to participate in our activity.

AN ULTHERAPY TREATMENT SHOULD ONLY BE PERFORMED AFTER A COMPLETE DISCUSSION OF THE RISKS RELATED TO THE TREATMENT AND WRITTEN INFORMED CONSENT OBTAINED.

The Ulthera® 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 Ultherapy®, 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.
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. Temporary local muscle weakness may result after treatment due to inflammation of a motor nerve. Temporary numbness may result after treatment due to inflammation of a sensory nerve.
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 Ultherapy treatment is not intended to produce the same results as an invasive surgical procedure.
The abov points of information have been specifically discussed and I have had the opportunity to ask any questions concerning this information:
I hereby give my consent and authorization and release this establishment and its agents of any claims that I have in the future connection with the described treatment.
Please answer whether you currently have or have had any of the following: metal or electronic implants
cardiac pacemakers, implanted defibrillators, implanted neurostimulators
pulmonary insufficiency
Ablative laser resurfacin
Face Peels or re surfacing dermabrasion
Face Lift or brow lift
Metal in treated area
Pregnant
Migraines
Skin Disease that may alter wound healing
Diabetes
Blood disorders
Epilepsy
Bells Palsy
Are you on Accutane
Are you on medications?
Have you had fillers or neurotoxin in the last 2 to 3 months
I confirm all the above is correct and I am fully aware and informed of the treatment and outcomes

Thanks for submitting!

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