Face HiFu Disclaimer
PATIENT CONSENT: This is an informed consent form that has been prepared to help inform you of the potential benefits and risks of facial HIFU. It is important that you read this information carefully and discuss fully with your practitioner before proceeding with treatment. It is also important that you take as much time as you need to consider the treatment carefully, weighing up all your options before reaching an informed decision. It is essential that you are aware of your right to have a second opinion and you are encouraged to ask any questions that come to mind throughout the entirety of the process. HIFU stands for High Intensity Focused Ultrasound, it works by using multiple beams of ultrasound to create thermal energy in the deeper skin layers and beneath the skin. Heating the tissue causes it to tighten as well as stimulating the production of new collagen fibers therefore improving the appearance of loose or ageing skin. It has been explained to me that the results vary from patient to patient. I understand that results will unfold over the course of 3 to 6 months. I am also aware that I may require more than one treatment session to achieve optimal results. I also understand that a non-invasive HIFU treatment is not intended to produce the same results as an invasive surgical procedure such as a face lift. Before each treatment, I will inform the practitioner of any changes to my medical details or details of any new medications that have been prescribed by my doctor. I also agree to comply with the recommended aftercare instructions. I hereby release the practitioner, clinic and the staff from liability associated with the procedure. My questions regarding the procedure have been answered satisfactorily. I understand that several appointments may be necessary to produce optimal results and I will be notified, in advance of each session of treatment, about the location where the next treatment session is going to take place and the identity of who is going to be involved in my care at each stage. I also understand that I will be kept informed of progress and that I can change my mind at any point.
RISKS AND SIDE EFFECTS: As with any medical procedure there are possible risks associated. HIFU is a safe and low risk procedure but some unwanted effects may be experienced. Common side effects you may experience from HIFU include mild discomfort or tenderness during and following the treatment. Immediately following treatment, the skin may appear red for a few hours. It is not uncommon to also experience slight swelling for
a few days following the procedure or tingling/tenderness to touch for days to weeks following the procedure, but these are mild and temporary in nature. Uncommon temporary effects may include bruising or welts (raised bumps on the skin), which resolve in hours to days. Rare risks of HIFU include skin burns and nerve inflammation. A burn to the skin may or may not lead to scarring. This should respond to simple medical care but there is an extremely small risk of permanent scaring if a skin burn is sustained. Temporary nerve inflammation is another rare risk of HIFU. This results in numbness or tingling in a select area of skin if a sensory nerve has been affected. This should normally resolve naturally in days to weeks. Extremely rarely temporary local muscle weakness may result after treatment due to inflammation of a motor nerve. I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice. This includes advice about: - the aims/motivations for having the procedure and the desired outcome - the risks inherent in the procedure - the risks inherent in refusing the procedure - the risks specific to me - the expected benefits of the treatment - the potential disadvantages of the treatment - alternative procedures and their pros and cons - including the option of no treatment at all - any uncertainties about and the likelihood of success of the procedure - any follow-up treatment that may be required
CLINICAL PHOTOS AND VIDEOS: I agree to and authorise the taking of clinical photographs and videos. I understand that these clinical photographs and videos will form part of and will be kept with my confidential medical records. I have been asked what information I want and would need in order to make an informed decision. I have been given the opportunity to discuss my desired outcome fully in order for me to make an informed decision.
I certify that I have read the above consent and that I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. No new information has become available that affects my decision to have the treatment or my decision to consent. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.