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7D ULTMAX HIFU - Client Consent Form

Please read carefully and fill out the following form to help us understand your suitability for treatment

Are you experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell?
Have you travelled internationally within the last 14 days?
Have you or any of your household members been diagnosed with COVID-19 WITHIN THE PAST 30 DAYS?
Are you pregnant, breast feeding, or trying to conceive?
Have you had any surgical procedure in the treatment area within the last 3 months or complete healing is still in progress?
Do you have any current or previous skin cancer (epithelioma and melanoma) or any benign/malignant tumors?
Do you have impaired motor functions (paralysis of facial muscles), presence of metallic materials or gold implants in bone/tissue in area that is being treated, or any infectious skin disease, such as Herpes Simplex infection?
Are you suffering from any active dermatological condition in the treatment area, such as eczema?
Are you suffering from cystic acne?
Do you suffer from diabetes, epilepsy, systemic lupus, erythematous, porphyria?
Do you have any active metallic implants such as pacemakers or defibrillators?
Are you using any medication and herbs known to induce photosensitivity?
Do you have have any pre-existing medical conditions or have any questions regarding your treatment, if so please contact your GP prior to your treatment to discuss your suitability for treatment?

CLINIC ADDRESS

Your treatment is up at Suite 603, Level 6, Harley Place, 251 Oxford St, Bondi Junction (diagonally opposite Zara exit of Westfields).  When you arrive, please take a seat in reception and your treatment specialist will be out at your confirmed appointment time.

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Note: If you are driving, please allow more than adequate time for traffic and parking. There is 2hrs free parking opposite in Westfields Mall.

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Thanks for submitting!

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