Download Threadlift Complications Reporting Form

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: ____________________________________________________________