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Client Details

Client Name *

Date of Birth *

Phone Number *

Email Address *

Treatment Date *

Practitioner / Witness Name *

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Consent Version

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Consent Version: ELURENA-CONSENT-HIFU-V1.0-2026

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ELURENA – HIFU TREATMENT CONSENT & LIABILITY FORM

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Elurena HIFU (High-Intensity Focused Ultrasound) is a non-surgical skin tightening treatment that uses ultrasound energy to stimulate collagen production. Results vary per person and may take several weeks to appear.

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What to Expect

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During or after HIFU treatment, you may experience:

Mild discomfort, heat, or tingling during treatment.Redness, swelling, or tenderness may occur for a few hours to days.Temporary bruising, numbness, or tingling may last up to several weeks.Best results appear gradually over 2–3 months.More than one session may be needed for optimal results.No refunds are offered for treatments.

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HIFU Contraindications

Do you have open wounds or skin infections in the treatment area? *

Yes No

Do you have severe or cystic acne in the treatment area? *

Yes No

Do you have metal implants or a pacemaker? *

Yes No

Do you have epilepsy or a history of seizures? *

Yes No

Are you pregnant or breastfeeding? *

Yes No

Do you have active skin conditions such as eczema, dermatitis, psoriasis, or similar conditions? *

Yes No

Have you had recent cosmetic procedures in the treatment area, including filler, Botox, laser, chemical peel, or similar treatment? *

Yes No

Do you have a history of keloid scarring? *

Yes No

Do you have any serious medical condition such as cancer, uncontrolled diabetes, or bleeding disorders? *

Yes No

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General Medical Declaration

Have you disclosed your full and accurate medical history to the practitioner? *

Yes No

Are you currently taking any medication that may affect treatment safety? *

Yes No

Have you had any recent cosmetic, medical, or aesthetic procedures in the treatment area? *

Yes No

Do you understand that treatment may be refused or postponed if there is a safety concern? *

Yes No

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HIFU Consent Confirmation

HIFU Consent Confirmation *

I understand the HIFU treatment, possible risks, contraindications, and limitations. I understand that results are not guaranteed and that multiple sessions may be required. I confirm that I have disclosed my full medical history and give consent to proceed with HIFU treatment.

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Optional Photography Consent

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I authorize Elurena and its staff to take photographs of me for documenting treatment progress and results, training, education, and marketing use. I understand my name will not be used, my face will not be shown unless I give specific permission, and I may revoke this consent in writing at any time.

Photography Progress Consent

I consent to photographs being taken for treatment progress documentation only.

Photography Training Consent

I consent to photographs being used for training and education.

Photography Marketing Consent

I consent to photographs being used for marketing, digital, print, or online purposes.

Photography Face Consent

I specifically consent to my face being shown, if required.

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Final Treatment Agreement

Treatment Information Confirmation *

I confirm that I have read and understood the HIFU treatment information shown in this form.

Risks and Limitations Confirmation *

I confirm that I understand the possible risks, side effects, contraindications, and limitations of HIFU treatment.

No Guaranteed Results Confirmation *

I understand that treatment results vary and are not guaranteed.

Multiple Sessions Confirmation *

I understand that more than one session may be required.

No Refunds Confirmation *

I understand that no refunds are offered for completed treatments.

Questions Confirmation *

I confirm that I have had the opportunity to ask questions before proceeding.

Consent to Proceed *

I consent to proceed with HIFU treatment.

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Signature

Client Signature *

Client Signature Date *

Practitioner / Witness Signature *

Practitioner / Witness Signature Date *

ELURENA – HIFU Treatment Consent Form

Client Details

Consent Version

ELURENA – HIFU TREATMENT CONSENT & LIABILITY FORM

What to Expect

HIFU Contraindications

General Medical Declaration

HIFU Consent Confirmation

Optional Photography Consent

Final Treatment Agreement

Signature