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THREADLIFT COMPLICATIONS REPORTING FORM Form Approved APTOS THREAD LIFTING PROCEDURE Complications Reporting Form Instructions Please complete this Thread lift Complications Reporting Form for any medical complications experienced by patients who receive thread lifting/armoring of face and body by Aptos threads. This form should be completed for any medical complication occurring either during or after the procedure. For clients experiencing a medical complication the following protocol should be followed: Complete the Thread lift Complications Reporting Form and submit by e-mail to Aptos scientific department immediately. If the complication was not resolved by the scientific department, re-submit until resolution. Threadlift Complications Reporting Form 1. Today’s date: / / (dd/mm/yyyy) 2. Country, City: ___________________________________________________________ 3. Clinic: __________________________________________________________________ 4. Doctor: Name: ________________________ Surname: ______________________ Mob.: ____________________________________________ e-mail: ____________________________________________ 5. Patient: ☐Male ☐Female Name: ________________________ Surname: ______________________ Age: _________________________________ 6. Date of procedure: / / (dd/mm/yyyy) 7. For which thread(s) are you reporting a complication? ☐Visage / Excellence method (EV) ☐Light Lift / Needle method ☐LLN2G ☐LLN2GSS ☐LLN2GSL ☐AN2G ☐AN2GSS ☐AN2GSL ☐Light Lift / Thread method ☐LLT2G ☐LLT2GS ☐AT2G ☐AT2GS ☐Light Lift / Spring method ☐LLS ☐LLSS ☐AS ☐ASS ☐Light Lift / Linea method (EE) ☐Nano / Excellence method (NV) ☐Nano / Spring method (NS7) ☐Nano / Vitis method (NV7) ☐Body / Excellence method (EB) ☐Body / Needle method (AN2/0) ☐Body / DRN method (ANDRN 60) ☐Body / Wire method ☐AW2/0 ☐AW3/0 ☐Sole / Rhinoplasty method ☐LLN2GSSP ☐AN2GSSP ☐Sole / Otoplasty method (AN4/0) ☐Sole / Suture method ☐LLST ☐AST 8. What was the area(s) of application? _______________________ _______________________ _______________________ 9. Date of complication report: / 10. Recommendations after the procedure: / (dd/mm/yyyy) _______________________________________________________________________ _______________________________________________________________________ 11. Type of complication (check all that apply): ☐Discomfort ☐Scarring ☐Bruising ☐Swelling ☐Infection ☐Bleeding ☐Damage to the deeper structures ☐Allergic reactions ☐Pigment changes (skin color) ☐Partial laxity correction ☐Delay healing ☐Loosing result (please indicate period) ☐Other________________________________________________________ Please, indicate Comments _______________________________________________________ 12. Underling disease(s)? ☐Yes _________________________________________________________ Please, indicate ☐No ☐Unknown 13. Contraindication(s)? ☐Yes _________________________________________________________ Please, indicate ☐No ☐Unknown 14. Taking other medications (prescription and OTC) if available: ☐ Aspirin ☐ NSAIDs ☐ Anticoagulants ☐ None ☐Other _______________________________________________________________ Please, indicate 15. Presence of inner body if available: ☐Silicone ☐Biopolymers ☐Fillers HA ☐Fillers of unknown origin ☐None ☐Other _______________________________________________________________ Please, indicate 16. Photos before and after 5 positions (please attach here or to the mail): ☐Yes ☐No 17. Recommendations after reporting a complication: _____________________________________________________________________ _____________________________________________________________________ 18. Outcome / result: _____________________________________________________________________ _____________________________________________________________________ Signature: ____________________________________________________________