Microneedling & Plasma Consent Form

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.
If you have any concerns in the meantime please contact us on +44 7765 245406.

The client has been informed about the facial skin treatment using the Philings technique. The nature of the procedure, it's purpose and benefits, duration and expected result, possible risks, painful and other temporary or permanent consequences have been explained to the client in detail.

Just Brows Inc. Ltd is obligated to perform the treatment in strict compliance with all hygiene and health protection measures. In order to perform the facial skin treatment in a safe manner, please answer the following health questions truthfully. This information is confidential and it shall also be handled in that way. It will not be shared with any third party.
Name*
Name*

First NameLast Name
Email*
example@example.com
Date of birth*

DayMonthYear
Date
Address*
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Phone number

Area CodePhone Number
Mobile number
Client Medical Health Form

Do you suffer from any of the following conditions or take any of the following medications?
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 any type of Hepatitis (A, B, C, D, E, F)?4. Are you HIV+?5. Do you suffer from any skin conditions (rosacea, impetigo, erysipelas, lupus, leroderma 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, makeup 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 (heart) related problems13. Do you take any prescribed medication on a daily basis e.g. aspirin, anti-coagulants?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 narcotics 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 any Botox, laser or chemical peels within the last 6 months?21. Do you routinely use Retinol-A, glycol or other exfoliation products?22. Do you wear contact lenses?23. Is your skin oily?24. Do/will you have your period at the time of treatment?25. Do you have a tendency to develop dark spots on the skin from wounds or sun damage?26. Do you scar easily from minor skin injuries?27. Do you bleed excessively from minor cuts?28. Do you have any prosthetic implants?29. If you have previously had PMU or any other cosmetic treatment did you have any problems with healing?30. Are you currently undergoing radiation or chemotherapy treatment?31. Do you have any history of cancer personally?32. Are you now or have you ever been on the acne treatment Accutane?33. Do you have any medical condition that has resulted in a medical professional requiring you to pre-medicate with an antiobiotic prio to a dental or other invasive procedure?NONE APPLY
If your response to any of the before mentioned questions was 'Yes', please write down a detailed explanation.
If you answered "Yes' to some of the questions above, it does not automatically mean that you are not a suitable candidate for treatment. Collecting data is of great significance to us because each client is a different individual thus an individual approach is required. The information you provide could also help in determining whether consultation with your doctor prior to the treatment is necessary or not. If you suffer from a disease/condition that is not mentioned in the table, please inform us below:
I consent to photography, filming, recording and/or digital imaging of the treatment to be performed and usage of the images for advertising purposes.*

YesNo
Explanation

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:*

I hereby release my Philings technician for all claims, demands, damages, actions and cause of action arising out of performance of the service(s).The technician accepts liability in compliance with the legal measures and regulations in the case of negligence or carelessness or intentionally or negligently caused injuries or threat to life, body and health.Client the informed in detail about specific risks of facial skin treatment using Philings technique.During the treatment, despite the staff expertise and all precautionary measures, client injury is possible.Despite the application of the most advanced and top quality products, allergic reaction is possible but rare. The client is informed about this and he/she assumed liability.During and after the treatment temporary swelling, reddens and/or itching may occur. Experience tells us that these symptoms are temporary.The results of applied treatment can be different due to differences in the skin quality, thus there is no warranty for the treatment success.Microneedling as well as plasma therapy always leads to injury of the skin. Therefore it is important to gently nurture your skin after to treatment to allow Healing without complications.Inadequate aftercare procedure in the healing phase of the skin can lead to poor results and your technician, or Just Brows Inc. Ltd, cannot be liable in the case of improper post-treatment care.
Micro-needling - 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.
Phi-Ion (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.
Binding Form
Please check boxes to confirm understanding:*

I confirm that I have read and understood the aforementioned information.I received clear and comprehensible answers to all the questions I asked.The procedure and the post-treatment care have been explained to me in detail andII did not get unrealistic guarantees regarding the expected results or the consequences of the said treatment.By signing the consent, I certify that I had a chance to ask about everything related to the implementation of treatment and that the Artist provided me with clear and comprehensible answers to all my questions.I have no other questions or objections.The treatment and post-treatment care was explained to me in detail and I understand and agree with it.
Consent

I certify that I have read and fully understand the contents of this microblading consent. I understand the risks and alternatives involved in the procedure(s) I have had the opportunity to ask questions, and all of my questions have been answered. I authorise Sarah Jane Sivyer as my Eyebrow Microblading Artist to perform on my body the Eyebrow Microblading procedure desired today. I CONFIRM THAT I HAVE READ AND UNDERSTAND THIS CONSENT FORM AND I AGREE TO BE BOUND BY IT. I AGREE THAT ALL THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
Signature*

Clear
Date of Signature:*

DayMonthYear
Date
I prefer to be contacted:

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Microneedling & Plasma Consent Form

Client Medical Health Form

Explanation

Micro-needling - Specific Risks

Phi-Ion (Plasma Treatment) - Specific Risks

Binding Form

Consent