About this template
An Ultrasound Cavitation Consent Form is an essential document used by estheticians, medical spas, and cosmetic clinics prior to performing non-invasive fat reduction treatments. This form helps practitioners collect vital client details, verify medical history, and screen for contraindications such as pregnancy, cardiovascular disease, implants, or active infections that could impact treatment safety. Furthermore, it outlines potential risks and secures formal client acknowledgment before procedures begin.
Using Doc2Form, you can instantly turn this structured layout into a ready-to-use Google Form, making client onboarding completely digital. Clients can fill out their health history and sign off on treatment policies directly from their mobile devices or computers before arriving at the clinic, eliminating clipboard clutter and saving valuable consultation time.
Key features
- Screen for contraindications and medical conditions instantly
- Collect comprehensive client background and contact information
- Streamline pre-treatment paperwork before the client arrives
- Easily share via direct link, QR code, or website embed
- Centralize responses in Google Sheets for effortless record-keeping
Use cases
Medical spas offering non-invasive body contouring and fat cavitation
Esthetician practices expanding into advanced cosmetic treatments
Laser and wellness clinics updating client intake and liability workf…
Laser and wellness clinics updating client intake and liability workflows
What this form collects
- Full Name (Short answer)Enter your first and last name as it appears on your government-issued ID.
- Date of Birth (Date)Please provide your birth date.
- Phone Number (Short answer)Enter the best phone number to reach you regarding appointments.
- Email Address (Short answer)We will send your appointment confirmation and pre-care instructions here.
- Residential Address (Paragraph)Provide your current street address, city, state, and zip code.
- Target Treatment Area (Checkboxes)Select the primary area(s) you wish to target during your session.
- Do you have any known allergies? (Multiple choice)Select Yes if you are allergic to any latex, topical numbing agents, oils, or metals.
- Allergy Details (Paragraph)If you answered Yes above, please list your allergies and typical reactions.
- Are you currently taking any prescription medications? (Multiple choice)Include blood thinners, steroids, or regular medications.
- Current Medications List (Paragraph)If yes, please list the medications and dosages.
- Are you currently pregnant or breastfeeding? (Multiple choice)Ultrasound cavitation is strictly contraindicated during pregnancy and breastfeeding.
- Do you have a history of cardiovascular disease or wear a pacemaker? (Multiple choice)Select Yes if you have heart conditions, pacemakers, or metal defibrillators.
- Do you suffer from severe hypertension or epilepsy? (Multiple choice)High blood pressure and seizure disorders require clinical clearance.
- Do you have an active cancer diagnosis or history of malignancy? (Multiple choice)Let us know if you are currently undergoing treatment or in remission.
- Have you had prior abdominal surgery or organ transplants? (Multiple choice)Include any recent surgeries in or near the treatment zone.
- Do you have any current infections, open wounds, or communicable diseases? (Multiple choice)Skin infections in the target area must be fully healed before proceeding.
- Client Acknowledgment (Multiple choice)I confirm that the medical history provided above is accurate and complete to the best of my knowledge. I understand the risks and benefits of ultrasound cavitation and voluntarily consent to undergo the procedure.
- Electronic Signature (Short answer)Please type your full legal name as your electronic signature.
- Date Signed (Date)Select today's date.
FAQ
What is ultrasound cavitation?
Ultrasound cavitation is a non-invasive cosmetic procedure that uses ultrasonic waves to break down fat deposits beneath the skin, which the body then naturally processes and eliminates.
Why is a consent and medical history form required for this treatment?
Certain medical conditions, medications, or implants can interfere with ultrasound waves or pose health risks during body contouring. Screening clients beforehand ensures the procedure is safe for them.
How can I share this form with my clients before their appointment?
Once generated in Google Forms, you can email the link to clients upon booking, include it in your appointment confirmation emails, or display a QR code at your front desk.
Can I customize the medical questions on this template?
Yes! Because the template lives in your Google Drive, you can easily add, remove, or modify any questions to match your clinic's specific protocol and insurance requirements.
Where are client responses stored?
All submissions are automatically routed to a secure Google Sheet linked to your form, allowing your team to review medical histories and consent records prior to each session.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.