Radiofrequency Skin Tightening Consultation/Consent Form | Aesthetics Forms Portal

Radiofrequency Skin Tightening Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical History

Are you currently taking any medication? *

Please specify: *

Do you have any allergies or intolerances? *

Please specify: *

Do any of the following apply to you? Please tick all that apply.

History of cancer Diabetes Active sores or skin disorders in the area to be treated Rosacea

If you have ticked any of the above please give detail:

Do you have any other medical conditions? *

Please specify: *

Are you pregnant or breastfeeding? *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

What are your skin concerns? *

What are your goals and expectations of the treatment? *

Fitzpatrick skin types:

1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

Which of the above skin types would you say is closest to your skin? *

Do you have any tattoos? *

Please list location(s) and size(s): *

Tanning History (Direct sun, Self-tanners, Spray tans etc.). Please list and include last date of use: *

Have you previously had any laser treatment? *

Previous Laser Treatment(s) - If known, please specify date, number of treatments, frequency, response to treatment, device used: *

Do you use sunscreen? *

Do you smoke? *

Treatment Information

Radiofrequency (RF) therapy, also called radiofrequency skin tightening, is a nonsurgical method of tightening your skin.

The procedure involves using energy waves to heat the deep layer of your skin known as your dermis. This heat stimulates the production of collagen.

Collagen is the most common protein in your body. It creates the framework of your skin and gives your skin its firmness.

As you age, your cells produce less collagen, which leads to sagging skin and wrinkles. Skin laxity occurs around age 35 to 40 when the quantity and quality of your collagen begins to decline.

RF waves heat the deep layer of your skin to between 122 and 167°F (50–75°C).

Studies have found that maintaining a temperature over 115°F (46°C) for over 3 minutes causes your body to release heat-shock proteins. These proteins stimulate your body to create new collagen fibers.

The procedure normally takes less than an hour and should be nearly painless.

Potential benefits of RF Therapy:

The primary benefits of RF therapy are tightening your skin and getting rid of wrinkles. However, RF therapy may also help fight sun damage due to its ability to stimulate the production of collagen.
Fighting sun damage - Exposure to ultraviolet (UV) rays can cause the collagen fibers in your skin to break down and become disorganized.
Face and body contouring - RF therapy may help tighten loose skin on your face and body by stimulating the production of collagen.
Reduce wrinkles and fine lines.

Pre Treatment Advice

You should try to avoid doing anything that will irritate your skin immediately before treatment. This includes sunbathing (natural or artificial). Practitioners are unlikely to treat someone who has sun burn for example, as they would be more likely to suffer pain from the addition of heat to the already damaged skin; however an established tan would be fine.

Some women find that their skin is more sensitive right before and during their menstrual cycle so if you are a woman, you might want to take this effect on pain threshold into consideration when scheduling your treatment appointment(s).

Aftercare Advice

Any deep exfoliation treatment such as chemical peels or skin needling, should be avoided for 7 days following your treatment.
Extreme exercise, swimming, spas, a hot shower and anything that involves increasing your body temperature to a high level, may increase the redness flare up of the area, for the first 24-48 hours.
A sunscreen will be applied immediately following your treatment, and you will need to reapply as necessary over the following 72 hours.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read and fully understood and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment.

I fully understand the above and consent to the Radiofrequency Skin Tightening treatment to be carried out.

Client Signature: *

Tap or click on the signature above to sign