Ultrasound Treatment Plan
Please complete all sections to document and authorize the ultrasound therapy plan.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Treating Clinician Name
*
First Name
Last Name
Diagnosis/Clinical Indication
*
Treatment Area
*
Ultrasound Frequency (MHz)
*
Please Select
1 MHz
3 MHz
Other
Treatment Intensity (W/cm²)
*
Please Select
0.5
1.0
1.5
2.0
Other
Treatment Duration (minutes)
*
Treatment Mode
*
Continuous
Pulsed
Number of Sessions Planned
*
Precautions or Contraindications
Treatment Goals
*
Additional Notes
Patient Signature
*
Submit Treatment Plan
Submit Treatment Plan
Should be Empty: