Microneedling & Plasma Consent Form
Please ensure that you have completed the Consent Form at least 48 hours prior to your treatment appointment. Failure to do so may result in your appointment being postponed.
Name
*
Name
*
First Name
Last Name
Email
*
example@example.com
Date of birth
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
*
Address
*
Street Address
Street Address Line 2
City
County
Postcode
Phone number
-
Area Code
Phone Number
Mobile/WhatsApp number
*
Format: 00000000000.
Medical Information
Do you suffer from any of the following conditions or take any of the following medications?
Which treatment are you having?
*
Microneedling
Plasma treatment
Both
Proposed treatment area(s)
*
Please list the areas to be treated.
Have you had any recent tanning, sunbed use, sunburn, significant sun exposure, or do you have a sunny holiday planned soon?
Yes
No
Please provide details
Are you currently taking any prescribed medicines, over-the-counter medicines, vitamins or supplements?
Yes
No
Do you have any allergy or sensitivity to topical or local anaesthetic, including lidocaine or prilocaine?
Yes
No
Do you have any allergy or sensitivity to latex, plasters, adhesives or antiseptics?
Yes
No
Are you currently taking, or have you recently taken, steroid or immunosuppressant medication?
Yes
No
Do you have any active infection, inflammation, dermatitis, open wounds, lesions or sunburn in or near the proposed treatment area?
Yes
No
Have you ever had a previous adverse reaction to microneedling, plasma treatment, topical anaesthetic or products used during treatment?
Yes
No
Have you had dermal fillers or other injectable cosmetic treatment within the last six months?
Yes
No
Please select all that apply:
*
1. Do you suffer from any blood disorders (thrombosis, haemophilia, anaemia, etc.)?
2. Do you have diabetes (type 1 or type 2)?
3. Do you have hepatitis?
4. Do you have HIV?
5. Do you suffer from any skin conditions (rosacea, impetigo, erysipelas, lupus, scleroderma or any other)?
6. Do you have a history of skin sensitivity (eczema or atopic dermatitis)?
7. Do you have any allergies to medication, food, metals, make-up or any other compound?
8. Do you suffer from any autoimmune diseases?
9. Are you prone to cold sores (herpes) or fever blisters?
10. Do you suffer from any acute or chronic infectious diseases?
11. Do you suffer from epilepsy or other seizure-related condition?
12. Do you have any cardiovascular or heart-related conditions?
13. Do you take any prescribed medication on a daily basis, for example, aspirin or anticoagulants?
14. Are you pregnant or breastfeeding?
15. Do you tend to develop keloid or hypertrophic scars?
16. Do you have a pacemaker fitted?
17. Do you have a problem with wound healing?
18. Have you consumed recreational drugs or alcohol in the past 24 hours?
19. Have you had surgery or any other medical intervention in the past 14 days?
20. Have you had botulinum toxin injections, laser treatment or a chemical peel within the last 6 months?
21. Do you routinely use tretinoin, retinoids, retinal, glycolic acid or other exfoliating products?
22. Do you wear contact lenses?
23. Do you have any metal plates, pins, implants or other implanted devices in or close to the proposed treatment area?
24. Are you currently undergoing radiotherapy or chemotherapy?
25. Do you have a personal history of cancer?
26. Are you currently taking, or have you recently taken, isotretinoin/Roaccutane?
NONE APPLY
Please provide further information about any condition, medication or treatment selected above:
Practitioner Treatment Record
Practitioner use only.
Fitzpatrick skin type
Please Select
I
II
III
IV
V
VI
Pigmentation history or risk notes
Practitioner name
Consultation date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Treatment date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Exact treatment area
Device used
Settings or needle depth
Cartridge or consumable batch number
Products or serums used
Topical anaesthetic used
Patch test details where applicable
Practitioner signature
Do you wear contact lenses?
Yes
No
Do you have any significant visual impairment?
Yes
No
Have you had previous eye surgery or recent laser eye surgery?
Yes
No
Do you have any retinal or corneal problems?
Yes
No
Do you suffer from dry eye?
Yes
No
Do you have recurrent conjunctivitis, styes or eye infections?
Yes
No
Do you have glaucoma, cataracts or any other eye disease?
Yes
No
Is plasma treatment proposed in or around the eyelids or eye area?
Yes
No
Is there any other medical condition, medication, allergy or recent treatment that we should know about?
I consent to photography, filming, recording and/or digital imaging of the treatment to be performed and usage of the images for advertising purposes.
*
Yes
No
General Risks and Client Understanding
Please read and confirm each statement below before proceeding.
I understand that before-and-after photographs are required for my confidential treatment and insurance records.
I give permission for my photographs or videos to be used for marketing, social media, website and educational purposes.
*
Yes, including my full face
Yes, but only cropped images of the treated area
No marketing use
General Risks and Client Understanding
*
I understand that microneedling and plasma treatments intentionally create a controlled response in the skin and that temporary redness, swelling, tenderness, tightness, itching, dryness or flaking may occur.
I understand that recognised risks include discomfort, pinpoint bleeding or bruising, infection, delayed healing, scarring, temporary or persistent changes in pigmentation, allergic or inflammatory reactions, and reactivation of cold sores where applicable.
I understand that results vary between individuals, that more than one treatment may be required and that no particular outcome or duration of results can be guaranteed.
I have disclosed all relevant medical conditions, medications, allergies, recent treatments and previous adverse reactions.
I agree to follow all pre-treatment and aftercare instructions and to contact Just Brows Inc. Ltd promptly if I experience an unexpected or concerning reaction.
I understand that alternative options, including having no treatment, are available.
I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.
Microneedling - Specific Risks
The client is informed in detail by the technician on the specific risks which may arise from the Philings treatment. The following risks are particularly explained to me as a client.
Please check ALL boxes to confirm understanding:
*
After the procedure, the skin will be red and flushed in a similar way to moderate sunburn. You may experience skin tightness and mild sensitivity to touch on the area being treated. These effects will diminish greatly a few hours following the treatment and within 24 hours the skin will be completely healed. After 3 days most visible erythema will be absolved.
To achieve desired results, it usually takes up to 3 treatments, with 2 weeks gap between each of them. The results last from 4-6 months.
Plasma Treatment - Specific Risks
The client is informed in detail by the technician on the specific risks which may arise from the Philingstreatment. The following risks are particularly explained to me as a client.
Please check ALL boxes to confirm understanding:
*
Clusters of yellowish spots up to 2mm in diameter will appear in the treated area and remain visible for up to 7 days. Eye lids may get swollen and become red after the treatment and the client may feel tingling. All these side effects should disappear within 7 to 10 days.
One treatment is usually enough to achieve desired results. After 1 month, on check up appointment, the technician determines if an additional treatment is necessary. The results are expected to last for at least 9 months.
Final Consent
Please check ALL boxes to confirm understanding:
*
I confirm that I have read and understood this consent form.
I understand the nature, purpose, limitations, alternatives and recognised risks of the treatment selected above.
I consent to Sarah Jane Sivyer of Just Brows Inc. Ltd performing the treatment selected above.
I confirm that the information I have provided is true and complete to the best of my knowledge.
I understand that payment is for the treatment provided, not a guaranteed outcome. Nothing in this consent form affects my statutory rights or excludes liability where it cannot lawfully be excluded.
I agree to follow the aftercare instructions provided.
I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.
I understand that I may withdraw my consent at any time before or during treatment.
I agree to tell my practitioner about any change in my health, medication or pregnancy status before every treatment appointment.
I confirm that I am aged 18 or over.
Signature
*
Date of Signature:
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
I prefer to be contacted:
Email
Phone call
WhatsApp
Submit
Should be Empty: