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Treatment Plan FormWebM2026-06-16T10:43:52+10:00

Treatment Plan Form

Ultraformer MPT Patient Consent Form

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CLIENT DETAILS

Client Name(Required)

Date of Birth

Consultation Date

Practitioner

PRIMARY CONCERNS

Main Concern #1

Main Concern #2

Main Concern #3

Client Goals

ASSESSMENT SUMMARY

Skin / Body Assessment Findings

Contraindications Identified

Relevant Medical Considerations

Photographs Taken

Yes

No

RECOMMENDED TREATMENT PLAN

Recommended Treatments

LPG Endermologie

Ultraformer MPT

Cold Plasma

Fibroblast Plasma

Enzyme Peel

TeslaChair

TeslaFormer

BMS Facial Massage

Infrared Sauna

Combination Program

TREATMENT SCHEDULE

Treatment 1

Treatment 2

Treatment 3

Treatment 4

Treatment 5

Recommended Frequency

Estimated Program Duration

EXPECTED OUTCOMES

Expected Improvements

Estimated Timeframe

Maintenance Recommendations

Limitations Discussed With Client

HOME CARE PLAN

Cleanser

Serum

Moisturiser

SPF

Supplement Recommendations

Lifestyle Recommendations

CLIENT COMMITMENT

Client Commitment(Required)

I understand treatment results vary between individuals.

I understand multiple sessions may be required.

I understand home care compliance affects outcomes.

I understand no exact result can be guaranteed.

PROGRESS REVIEW PLAN

2 Week Review

6 Week Review

12 Week Review

Additional Reviews

PRACTITIONER NOTES

Practitioner Notes

SIGNATURES

Client Signature

Date

Practitioner Signature

Date

Contact Info

Level 1/42 East Concourse, Beaumaris, Vic 3193
Phone: 0448 892 914
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