HIFU Non-Surgical Treatment Form
High Intensity Focused Ultrasound Lifting & Tightening Procedure
Select an Appointment Date
*
What are your expectations?
Nothing crazy, slight enhancement
I want a noticeable change
I need a major transformation!
Other
How old are you?
Have you gotten Botox or fillers in the last 4 weeks? If yes, what was the exact date?
Do you take blood thinning medication? 1 week prior to treatment you must stop taking any blood thinning medicines such as Aspirin, anti-inflammatory medication, and fish oil supplements. Medications such as Warfarin or St. John’s wort will require GP Consent.
Please check the following if they apply to you.
Breastfeeding or Pregnancy
Diabetes
Severe or Cystic Acne
Herpes or HIV
Heart Condition or Pacemaker
Undiagnosed lumps
Bell’s Palsy
Skin thinning medicine (Roaccutane)
Thyroid Disease
Epilepsy
Do you have any allergies?
Customer Information
Name
First Name
Last Name
Phone Number
Email
example@example.com
I’m done
Should be Empty: