HIFU / Ultherapy Consent

This section is the important one. HIFU uses focused ultrasound energy, and some of these answers rule the treatment out completely rather than simply needing an adjustment.

• Do you have a pacemaker, implanted defibrillator, or any other active electronic implant? Yes No
• Do you have metal implants, plates, screws or surgical clips in or near the treatment area? Yes No
• Do you have metal dental implants, plates or extensive metal dental work? Yes No
• Do you have dermal fillers, threads or silicone implants in the treatment area? Yes No
• Are you pregnant or breastfeeding? Yes No
• Do you have open wounds, lesions, active infection or severe cystic acne in the treatment area? Yes No
• Do you have a bleeding or clotting disorder, or take anticoagulants? Yes No
• Do you have epilepsy or a seizure disorder? Yes No
• Do you have an autoimmune condition, uncontrolled diabetes, or liver disease? Yes No
• Have you ever had a keloid or raised, thickened scar? Yes No
• Are you currently having treatment for cancer, or have you in the last 12 months? Yes No
• Have you taken Accutane / isotretinoin in the last 6 months? Yes No