Ultraformer MPT Comprehensive Consent Form

Ultraformer MPT Patient Consent Form

CLIENT DETAILS

Full Name(Required)

Date of Birth

Address

Street Address

Mobile

Emergency Contact

Emergency Contact Number

GP Name (Optional)

MEDICAL HISTORY

Medical History

Pregnancy

Breastfeeding

Diabetes

Cancer

Autoimmune Disease

Thyroid Disorder

Epilepsy

Pacemaker/Defibrillator

Metal Implants

Bell's Palsy

Keloid Scarring

Herpes Simplex

Heart Condition

High Blood Pressure

Blood Thinners

Poor Wound Healing

Active Infection

Dental Implants

Gold Threads

Recent Surgery

Recent Injectables

Neurological Disorder

Current Medications

Previous Surgeries

Other Medical Conditions

AESTHETIC HISTORY

Previous Aesthetic Treatments

Anti-Wrinkle Injections

Dermal Fillers

PDO Threads

HIFU

Ultraformer

RF Microneedling

Morpheus8

Fibroblast Plasma

Cold Plasma

Laser Resurfacing

Chemical Peels

Dates / Details

CLIENT CONCERNS

Client Concerns

Jowls

Double Chin

Neck Laxity

Jawline Definition

Nasolabial Folds

Marionette Lines

Eyelid Laxity

Brow Lift

Full Face Tightening

Body Tightening

PRACTITIONER ASSESSMENT

Fitzpatrick Skin Type

III

Skin Laxity

Facial Fat Volume

Neck Laxity

Jowl Severity

Treatment Suitability

Practitioner Notes

Ultraformer MPT Information

Ultraformer MPT is a non-surgical skin lifting and tightening treatment using Micro-Focused Ultrasound technology.

Results may take 6–12 weeks to become visible and may continue improving for up to 6 months.

Multiple treatments and maintenance treatments may be required.

EXPECTED RESULTS & LIMITATIONS

Expected Results & Limitations(Required)

I understand results vary between individuals.

I understand no exact cosmetic outcome can be guaranteed.

I understand maintenance treatments may be recommended.

I understand Ultraformer MPT is not a replacement for surgery.

RISKS & POSSIBLE SIDE EFFECTS

Risks & Possible Side Effects Acknowledged(Required)

Redness

Swelling

Tenderness

Bruising

Tingling

Temporary Numbness

Jaw Tenderness

Temporary Nerve Irritation

Temporary Muscle Weakness

Headache

Uneven Tightening

Temporary Lumps

Fat Loss

Asymmetry

Burns (Rare)

Unsatisfactory Cosmetic Outcome

Contraindications

Pregnancy/Breastfeeding
Pacemaker or implanted electronic device
Active Cancer
Active Infection or Open Wound
Metal Implants / Gold Threads
Recent Surgery / Threads / Fillers
Severe Skin Disease
Uncontrolled Diabetes

PHOTOGRAPHY, VIDEO & MARKETING CONSENT

Photography & Marketing Consent(Required)

Clinical Records Only

Education & Training

Website Marketing

Social Media Marketing

Before & After Photos

I Do Not Consent To Marketing Use

Photography Consent Signature

Photography Consent Date

PRIVACY POLICY

I consent to collection and storage of my personal and health information.

I consent to communication by SMS, phone and email.

Clinical records and photographs may be retained in accordance with Australian law and insurer requirements. Information will only be disclosed where legally required or with consent.

FINANCIAL, REFUND & CANCELLATION POLICY

Completed treatments are non-refundable except where required by Australian Consumer Law. Late cancellations, no-shows and insufficient notice may result in fees or loss of deposit. Unused package sessions are non-transferable unless approved by management.

COMPLAINTS POLICY

Clients should contact the clinic promptly regarding concerns.

Complaints Policy Agreement(Required)

I agree to attend a review appointment if requested.

I understand photographs may be required to assess concerns.

This treatment is cosmetic and not intended to diagnose, treat, cure or prevent disease. No verbal or written statement constitutes a guarantee of outcome. Nothing in this agreement excludes rights under Australian Consumer Law. The practitioner reserves the right to refuse or postpone treatment if unsuitable. I authorise referral for medical review if an adverse event occurs.

PATIENT DECLARATION

Patient Declaration(Required)

I have read and understood this document.

I have had the opportunity to ask questions.

I understand the risks, limitations and aftercare requirements.

I voluntarily consent to treatment.

TREATMENT RECORD

Treatment Date

Practitioner

Machine Serial Number

Treatment Areas

Face

Neck

Eyes

Body

Cartridges Used

Mode

Normal

MPT

Shot Count

Products Applied

Treatment Notes

Aftercare

SPF50+ daily
Avoid heat, sauna, steam rooms and strenuous exercise for 24–48 hours
Avoid laser, RF, needling, peels and aggressive skin treatments until advised
Maintain hydration and normal nutrition
Contact the clinic if severe pain, blistering, infection, facial weakness or prolonged numbness occurs

FOLLOW-UP REVIEW

2 Week Review

6 Week Review

12 Week Review

Before & After Photos Reviewed

SIGNATURES

Patient Name(Required)

Patient Signature(Required)

Date

Practitioner Name

Practitioner Signature