HIFU Consent Form

    Explanation of HIFU:
    HIFU stands for High-Intensity Focus Ultrasound, HIFU is a non-surgical treatment that uses focused ultrasound technology to tighten and lift facial and body skin. HIFU effects 3 different layers of the superficial and dermis along with SMAS, which is the same layer of the tissue that surgeons pull tight in a facelift. As thermal energy safely heats this tissue, it contracts resulting in tightening of the skin and formation of new collagen, which provides a long-term tightening effect.
    HIFU directly delivers the ultrasound energy to skin and subcutaneous tissue that can stimulate and renew the skin’s collagen and thus consequently improving the texture and reducing sagging of the skin.

    Benefits of HIFU Treatments
    i) Wrinkle removal
    ii) Skin lifting and tightening
    iii) Skin smoothing improves sagging and other signs of the aging phenomenon
    iv) Suitable for face, neck, and body

    As stated above, the purpose of this procedure is to tighten sagging skin in the areas indicated above. The procedure requires more than one treatment and may produce some reduction in the appearance of sagging skin and/or wrinkles. The total number of treatments and clinical results may vary between individuals.
    Most patients require a number of treatments over several months with gradual results occurring over this time. On occasion, there are patients that do not respond to treatments and so the outcome cannot be guaranteed. I was also informed about the other alternative methods as well as their benefits and disadvantages.
    I understand that for ideal results, this procedure can be combined with radio-frequency, surgical options. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am also aware that follow-up treatments may be necessary for desired results.

    1. I consent for the Body Contour Studio team to do my 4D HIFU treatment
    2. I am currently not on blood thinners, or if I am taking blood thinners, I have check with my prescribing physician and he/she has given me permission to have this procedure knowing the risks associated
    3. HIFU is a non-surgical treatment to tighten and lift sagging skin
    4. I understand that results vary from each individual and, occasionally, the collagen building on the inside that helps counter the effects of gravity does not have a visible effect on the outside.
    5. I understand that results will unfold over the course of 2-3 months and that some patients may benefit from more than one treatment.
    6. I also understand that a non-invasive HIFU treatment is not intended to produce the same results as an invasive surgical procedure.
    7. I understand that there can be discomfort during the treatment.
    8. I understand that the treated skin may appear red for a few hours, and experience slight swelling for the next few days or week post treatment
    9. I understand that it is not uncommon to experience a tingling sensation or tenderness in the area when it’s touched for a few days or week post treatment. This is usually mild and temporary in nature.
    10. Rarely some patients may experience temporary effects such as bruising, swelling and welts which resolves in hours to days.
    11. Numbness may occur and can resolve in days or weeks.
    12. 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.
    13. I understand that if I have dermal filler within the past 3 months or neurotoxin (Botox, Dysport) within the past 2 weeks. It is possible that the heat from HIFU may breakdown and diminish the effectiveness of such.
    14. I understand that after my treatment, it is recommended to avoid dermal filler injections for 2 months & neurotoxin (Botox, Dysport) for 2 weeks.
    15. I understand that I can take pain tablets such as Panadol prior to my treatment for pain management, if needed
    16. I understand the risks associated with this treatment and have discussed other alternative methods that are available
    17. I have read all the information provided in relation to this treatment.
    18. I will contact Body Contour Studio if I have any concerns about the treatment.
    19. I am over the age of 18 years old.
    20. I consent to photographs and video footage which will be retained as a private record for the clinic and practitioner.

    Medical and Surgical History

    Gender (required)

    Do you have any of the following? (Tick where applicable)

    Active wounds.
    Active severe or cystic facial acne.
    Metal stents in the treatment area.
    Implanted electrical devices.
    Pregnant or lactating.
    Bell’s palsy.
    Mechanical or other implants in the treatment area.
    Active or local skin disease that may alter wound healing*.
    Autoimmune disease.
    Herpes or cold sores.
    Hemorrhagic or bleeding disorders.
    Undergone the following cosmetic procedure in the brow or lower face and neck area: Facial skin tightening procedure treatment within the last 1 year.
    Filler (i.e. juvederm® or Sculptra®) within the last 3-6months.
    Neurotoxin (i.e. Botox® or Dysport®) within the last 3-6months.
    Ablative resurfacing laser treatment.
    Non-ablative resurfacing laser treatment.
    Dermabrasion or deep facial peels.
    Lip o-plasty in the face or neck regions.
    Facelift or blepharoplasty or brow lift.

    I have read and understood all the information provided and I have had the opportunity to ask any questions concerning the nature of the treatment, its expected results, and its possible risks and complications. I hereby release Body Contour Studio and its staff from liability associated with the above procedure. I authorise the staff of Body Contour Studio to perform High Intensity Focused Ultrasound treatment on my body.