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The First Step

Consent Form

We are excited to begin your treatment. Please fill out the information below before being treated.

Fill Out the Form Below to Provide Consent

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PATIENT INFORMATION

Name*
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Address*

WHAT BRINGS YOU IN TODAY?

What are your primary concerns? (Check all that apply)
What are your primary concerns? (Check all that apply)
Skin Quality*
Pigmentation*
Acne & Scarring*
Redness & Inflammation*
Regenerative Goals*
Body Concerns*

TREATMENT GOALS

What are your goals for treatment?*

PREVIOUS AESTHETIC TREATMENTS

I understand that CellSound® is generally considered a low-risk, non-invasive procedure; however, complications may occur. Potential side effects may include:

  • Temporary redness
  • Mild swelling
  • Warmth in treated area
  • Tingling sensation
  • Mild tenderness
  • Temporary sensitivity
  • Temporary itching
  • Temporary muscle soreness
  • Bruising (rare)
  • Headache (rare)
  • Lack of improvement
  • Unsatisfactory cosmetic outcome

Although uncommon, unforeseen complications may occur.

I understand that no guarantee has been made regarding my results.

Have you ever had any of the following?*

CURRENT SKINCARE ROUTINE

Prescription Skin Products
Active Ingredients Used Regularly

MEDICAL HISTORY

Do you currently have or have you ever been diagnosed with:

General Medical Conditions*
Skin Conditions*
Infectious History*
Implantable Devices*

FEMALE PATIENTS

Are you currently:

MEDICATIONS

Are you currently taking:

SUPPLEMENTS

Latex Allergy*
Adhesive Allergy*

LIFESTYLE FACTORS

Do you currently:
Drink Alcohol?*
Use Nicotine Products?*
Smoke or Vape?*
Use Tanning Beds/ Sunbathe?*
Wear Daily Sunscreen?*
Exercise Regularly?*
Drink 64 oz or more of water daily?*

PATIENT CERTIFICATION

I certify that the information provided is accurate and complete to the best of my knowledge. I understand that failure to disclose medical information may increase the risk of complications and may affect my treatment outcomes.

Clear Signature
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