Confidential Client Assessment And Treatment Record

Gender(Required)

Name(Required)

Address(Required)

Street Address Address Line 2

Phone(Required)

Age(Required)

Weight(Required)

Height(Required)

MEDICAL HISTORY / PATIENT ASSESSMENT

Do you have any of the following conditions?

Active severe or cystic facial ACNE(Required)

Yes

Open facial wound or lesion(Required)

Yes

Metal stents in the treatment area(Required)

Yes

Implanted electrical devices(Required)

Yes

Pregnancy or lactating(Required)

Yes

Suffering from migraines(Required)

Yes

Suffering from Bell’s palsy(Required)

Yes

Haemorrhagic or bleeding disorders(Required)

Yes

Mechanical or other implants in the treatment area(Required)

Yes

Active or local skin disease that may alter wound healing(Required)

Yes

Autoimmune Disease(Required)

Yes

Epilepsy(Required)

Yes

Herpes or cold sores(Required)

Yes

Herpes or cold sores(Required)

Yes

Diabetes(Required)

Yes

1: Ultraformer is contraindicated for use.
2: Ultraformer is not recommended for use directly over this.
3: Ultraformer has not been evaluated for use

General Health(Required)

No issues

Minor issues

Chronic issues

Smoking History(Required)

Never Smoked

Ex-smoker

Light smoker

Heavy smoker

Sun Exposure(Required)

Never use sun screen

Occasionally use sun screen

Always use sun screen

Do you have any allergies? If so, specify :(Required)

Do you have any chronic illness? If so, specify :(Required)

HAVE YOU UNDERGONE ANY OF THE FOLLOWING COSMETIC PROCEDURES IN THE BROW OR LOWER FACE AND NECK AREA?

Facial skin tightening procedure treatment within the last 1 year(Required)

Yes

Treatment name(Required)

Location treated(Required)

Date of last treatment(Required)

Non-Ablative rejuvenating laser treatment(Required)

Yes

Location treated(Required)

Treatment name(Required)

Date of last treatment(Required)

Filler Injection within the last 3-6 months(Required)

Yes

Location treated(Required)

Treatment name(Required)

Date of last treatment(Required)

Dermabrasion, microdermabrasion or deep facial peels(Required)

Yes

Location treated(Required)

Treatment name(Required)

Date of last treatment(Required)

Botulinum Toxin Injection within the last 3-6 months(Required)

Yes

Location treated(Required)

Treatment name(Required)

Date of last treatment(Required)

Location treated(Required)

Treatment name(Required)

Date of last treatment(Required)

Liposuction in the treatment areas(Required)

Yes

Ablative resurfacing laser treatment(Required)

Yes

Location treated(Required)

Treatment name(Required)

Date of last treatment(Required)

HAVE YOU UNDERGONE ANY OF THE FOLLOWING COSMETIC PROCEDURES IN THE BROW OR LOWER FACE AND NECK AREA?

Are you currently taking any of following medications below?

Accutane within the last 12 months(Required)

Yes

Anticoagulants or antiplatelet drugs(Required)

Yes

Immunosuppressant drugs(Required)

Yes

List all medications and supplements below. Be sure to include all prescription or non-prescription medications.

MEDICATION - DISEASE / REASON - DOSE - FREQUENCY - DATE STARTED - DATE LAST TAKEN

PATIENT ASSESSMENT (Clinician Use Only)

UPPER FACE (FOREHEAD / EYES)

Skin Laxity : Sagging skin or hooding on the eyelid; eyelid droopiness(Required)

NONE

MILD

MODERATE

SEVERE

Volume : Presence of eye bags; infra-orbital puffiness(Required)

NONE

MILD

MODERATE

SEVERE

Skin Quality : Fine lines, crepiness/wrinkles, and/or poor elasticity/ frown lines, forehead lines, smile lines(Required)

NONE

MILD

MODERATE

SEVERE

LOWER FACE (CHEEKS / JAWLINE)

Skin Laxity : Fine lines, crepiness/wrinkles, and/or poor elasticity(Required)

NONE

MILD

MODERATE

SEVERE

Volume : Presence of heaviness in lower face, loss of jaw definition, and/or nasolabial fold(Required)

NONE

MILD

MODERATE

SEVERE

Skin Quality : Fine lines, crepiness/ wrinkles, and/or poor elasticity(Required)

NONE

MILD

MODERATE

SEVERE

SUBMENTUM

Skin Laxity : Fine lines, crepiness/wrinkles, and/or poor elasticity(Required)

NONE

MILD

MODERATE

SEVERE

Volume : Presence of excessive subcutaneous fat(Required)

NONE

MILD

MODERATE

SEVERE

Skin Quality : Fine lines, crepiness/ wrinkles, and/or poor elasticity/Loss of jaw definition / Laxity over jaw line(Required)

NONE

MILD

MODERATE

SEVERE

NECK

Skin Laxity : Fine lines, crepiness/wrinkles, and/or poor elasticity(Required)

NONE

MILD

MODERATE

SEVERE

Volume : Thickness of skin / amount of tissue, presence of neck folds(Required)

NONE

MILD

MODERATE

SEVERE

Skin Quality : Fine lines, crepiness/ wrinkles, and/or poor elasticity(Required)

NONE

MILD

MODERATE

SEVERE

OVERALL ASSESSMENT

CLINICAL NOTES:(Required)

PATIENT SKIN CONCERNS:(Required)

EXPECTED CLINICAL OUTCOMES and treatment goal:(Required)

WHAT IS THE PATIENT AGING STYLE? (1 Sinker, 2 Sagger, 3 Wrinkler)(Required)

1 Sinker

2 Sagger

3 Wrinkler

PATIENT OVERALL LAXITY RATING(Required)

COMBINATION TREATMENT and treatment plan:(Required)

PRESCRIPTION FOR TREATMENT

TREATMENT 1:(Required)

TREATMENT 2:(Required)

TREATMENT 3:(Required)

TREATMENT 4:(Required)

TREATMENT 5:(Required)

TREATMENT 6:(Required)

RESULTS MAINTENANCE

REVIEW APPOINTMENT:(Required)

MAINTENANCE APPOINTMENT:(Required)

CONSULTATION RECORD

PATIENT:

TREATMENT CHECKLIST

Pre-treatment photos taken(Required)

Yes

Procedure reviewed with patient :(Required)

Yes

Patient questions answered :(Required)

Yes

Informed Consent signed :(Required)

Yes

Photo Consent signed :(Required)

Yes

Ultraformer III treatment date :(Required)

Pre-medication order :(Required)

Ultraformer III treatment record printed from system :(Required)

Yes

Ultraformer III patient record completed :(Required)

Yes

TREATMENT DATE:

FOLLOW UP CHECKLIST

Aesthetic care plan discussed :(Required)

Three month follow-up appointment scheduled :(Required)

1st follow-up date(Required)

Photos taken(Required)

R45

R90

L45

R90

2nd follow-up date(Required)

Photos taken(Required)

R45

R90

L45

R90

TREATMENT #:(Required)

NEXT TREATMENT:(Required)

OTHER:(Required)

PROGRESS NOTES

FOREAHEAD:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

OTHER NOTES:(Required)

EYES:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

OTHER NOTES:(Required)

CHEEKS:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

OTHER NOTES:(Required)

SUBMENTUM:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

6.0mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

6.0mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

6.0mm

OTHER NOTES:(Required)

NECK:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

OTHER NOTES:(Required)

SPOT TREATMENT:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

OTHER NOTES:(Required)

SPOT TREATMENT:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

OTHER NOTES:(Required)

SPOT TREATMENT:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

OTHER NOTES:(Required)

CLINICIAN:(Required)

Signature

Do you have any of the following conditions?

HAVE YOU UNDERGONE ANY OF THE FOLLOWING COSMETIC PROCEDURES IN THE BROW OR LOWER FACE AND NECK AREA?

HAVE YOU UNDERGONE ANY OF THE FOLLOWING COSMETIC PROCEDURES IN THE BROW OR LOWER FACE AND NECK AREA?

PATIENT ASSESSMENT (Clinician Use Only)

UPPER FACE (FOREHEAD / EYES)

LOWER FACE (CHEEKS / JAWLINE)

SUBMENTUM

NECK

OVERALL ASSESSMENT

PRESCRIPTION FOR TREATMENT

RESULTS MAINTENANCE

CONSULTATION RECORD

PATIENT:

TREATMENT CHECKLIST

TREATMENT DATE:

FOLLOW UP CHECKLIST

PROGRESS NOTES

FOREAHEAD:

CARTRIDGE / DEPTH:

EYES:

CARTRIDGE / DEPTH:

CHEEKS:

CARTRIDGE / DEPTH:

SUBMENTUM:

CARTRIDGE / DEPTH:

NECK:

CARTRIDGE / DEPTH:

SPOT TREATMENT:

CARTRIDGE / DEPTH:

SPOT TREATMENT:

CARTRIDGE / DEPTH:

SPOT TREATMENT:

CARTRIDGE / DEPTH:

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