Jet Plasma Client Medical History and AFTERCARE Consent Form

Full Name

Date

Email

example@example.com

Address

How were you referred to our facility?

Current Medications (please list)

Have you taken Accutane within the last year? Yes -or- NO

Allergies (please list)

Please Read Carefully - Have you had or do you currently have any of the following? Indicate YES by checking any that apply.

** If you suffer from any of the above, it is important that you notify your technician so that they can can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. Additional Notes:

PLEASE READ CAREFULLY AND INITIAL / SIGN WHERE INDICATED.

Ensure all points below have been discussed with the technician. You are signing to state that you understand and accept these terms.

1. I acknowledge that any information contributed to me is true, to the best of my knowledge and that the present condition of the area that has been treated, or will be treated, is stated on this record. I fully understand Bella Day Spa, LLC is providing a beauty service. There is no medical treatment involved. Plasma Pen and/or Jet Plasma Treatment is an Art - not an exact science - and cannot guarantee an exact shrinkage result due to skin elasticity and individual which includes client's health, genetics, lifestyle factors and following proper after care. (Initial Here)

2. I understand that Jet Plasma requires sessions, minimum of 3 is suggested for best results and that I may be required to return for additional treatments before the overall procedures is deemed complete. The payment for any additional work, if applicable, will be agreed prior to the treatment commencing. Depending upon area of treatment, additional treatments cannot be performed until 6-8 weeks after 8 sessions in the same area to allow sufficient healing time. (Initial Here)

3. I realize that with any beauty service there may be certain risks, which must be understood. I will be fully responsible for any and all results, which may arise from these beauty services. I do nearby agree to hold Bella Day Spa, LLC, their affiliates and employees/students free from any and all claims or suits for damage, for injuries or complications resulting from any beauty services provided by Bella Day Spa, LLC. I understand that any spot removals. skin revision work performed may result in loss or gain of natural skin pigment. (Initial Here)

4. The skin type of every client is different and although Jet is safe for all Fitzpatrick, it is important ou follow our aftercare instructions. Additional sessions may be advised, after the healing process is complete. (Initial Here)

5. I understand that taking before and after photographs of the said procedures is a requirement of such procedure. I grant permission for the use of the photographs, or electronic media images as identified, in any presentation of all kinds. (Initial Here)

6. I have received Pre and Post procedure instructions and will strictly adhere to them. I understand that my failure to do so may jeopardize my chances for a successful outcome. (Initial Here)

7. I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medical history, it is my responsibility to inform the technician. (Initial Here)

8. I am aware that any skin altering procedures such as Laser treatments, plastic surgery, implants, injectables and weight gain or loss, may alter the treatments look. (Initial Here)

Jet Plasma

CONSENT TO FOLLOW AFTERCARE

I agree to follow the aftercare instructions provided below. I understand if I do not follow the AFTERCARE instructions I am being provided, I may experience a negative outcome. A minimum of 3 sessions are required for Jet Plasma. Aftercare instructions:

1. Following your treatment, due to the channels in the skin being open, it is important that noting is applied to the skin for 12 hours other than what your skin care professional puts on your skin.

2. No makeup can be worn after the treatment for 12 hours.

3. No exercise, Sauna, Steam room for 12 hours.

4. DO NOT forget to schedule your next session.

5. After 12 hours, you can resume your normal skincare routine. DO NOT forget your sunscreen.

(Initial Here)

I, the client, agree with all points listed and discussed, and wish to proceed as recorded with procedure with Bella Day Spa, LLC. I participated fully in the decision for the selected area or areas intended for my Jet Plasma Pen Treatment. I certify that I have read and initialed the above paragraphs. I have had it explained to my understanding therefore I consent to this procedure. I accept full responsibility for the decision to receive this treatment and do not hold Bella Day Spa, LLC responsible for any adverse reaction.

(CLIENT'S FULL NAME - PRINTED)

Client Signature

Date(M/D/Y)

Date

Treatment Agreement

Bella Day Spa confirms that I have checked all paperwork including consent forms and medical history. I have discussed all procedure points with my client and they understand all elements of the Jet Plasma Pen Treatment. Aftercare advice has been verbally presented to the client and written instructions will be provided.

Technician Signature

Date: (M/D/Y)

Date