Ultherapy Consent Form

The Ulthera® System delivers a low amount of focused ultrasound energy to the skin. The heat from the ultrasound stimulates new collagen to form. I understand that there can be discomfort during the treatment when the ultrasound is being delivered. I’ve discussed with my practitioner the options available to me to optimize my comfort during the procedure.

 Immediately following Ultherapy®, the skin may appear red for a few hours. It is not uncommon to experience slight swelling for a few days following the procedure or tingling/tenderness to the touch for days to weeks following the procedure, but these are mild and temporary in nature.

Occasional temporary effects may include bruising or welts, which resolve in hours to days, or numbness in a select area, which resolves in days to weeks.

As with any medical procedure, there are possible risks associated with the treatment. There is a remote risk of a burn that may or may not lead to scarring (either of which will respond to medical care), or temporary nerve inflammation, which will resolve in a matter of days to weeks. Temporary local muscle weakness may result after treatment due to inflammation of a motor nerve. Temporary numbness may result after treatment due to inflammation of a sensory nerve.

It has been explained to me that the results vary from patient to patient, and, occasionally, the collagen building on the inside that helps counter the effects of gravity does not have a visible effect on the outside. I understand that results will unfold over the course of 2 to 3 months and that some patients may benefit from more than one treatment. I also understand that a noninvasive Ultherapy treatment is not intended to produce the same results as an invasive surgical procedure.

I certify that the preceding medical, personal and skin history statements are true and correct to my knowledge.  I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history as needed.  A current medical history is essential for the caregiver to execute appropriate treatment procedures.


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Signature Certificate
Document name: Ultherapy Consent Form
lock iconUnique Document ID: 77348cecde02ee4d4eea743a97b7890bf13623a8
Timestamp Audit
May 20, 2020 9:05 pm PDTUltherapy Consent Form Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP