DermaLux Plaxel Plasma Pen_Fibroblast Consult Form

Date:

Date

Full Name:

Address:

Telephone:

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Email:

example@example.com

DOB:

Introduction: plaxel Plasma Pen is a True Plasma device, non-invasive treatment that will be performed using CE/TGA approved (FDA pending) approved equipment and best practices safety and hygiene techniques to shrink, tighten, lift and rejuvenate the skin using a sterile disposable probe. Your specialist is trained and certified by World plaxel Plasma Pen, wiith full certication and insurance.

Before carrying out the treatment, YOU, as a client are required to complete and sign all relevant areas of this consultation record to give your absolute consent to the treatment. You will need to disclose your full medical history to determine whether you are a suitable candidate for Plasma Pen. If the specialist does not think you are suitable, then the treatment cannot be performed.

Pr9vider will discuss your Plasma Pen treatment with you, in full, including what healing, recovery and downtime will be involved and the anticipated benefits. Realistic expectations will be agreed and any risks will be discussed. She will also discuss any further treatments needed to achieve the desired outcome. You will receive a separate aftercare form for you to read, sign and keep for your short and medium term healing process. It is absolutely essential you follow these instructions fully.

This treatment is elective and not medically necessary.

"Fibroblasting” with the Plasma Pen is an artform, not a direct science. It cannot always guarantee a measured shrinkage result due to individual skin elasticity, healing process based on age, health and lifestyle.

Results are accumulated over time and if multiple treatments are performed. The payment for additional treatments, if applicable will always be agreed upon prior to your treatment commencing

Additional treatments will not be performed until 12 weeks after the date of your initial treatment in order to allow for proper healing.

Photographs are required BEFORE, DURING and AFTER the treatment. I hereby grant that my photographs will be stored with my file. I consent that my photographs be used for advertiilesing, marketing and social media purposes..

Every client is different and the healing process will vary. In RARE cases, there may be discoloration to the skiin.

There may be minor discomfort depending on the area being treated.

The treatment includes delivering a highly controlled, precise and predictable micro-trauma to the surface of the skin. Plasma gas is completely safe. We work above the skin. We do not cause or leave any wound open. We do not damage the surrounding tissue and there is no risk of infection though you may experience a mild smell of charring during the treatment. This is normal.

Swelling and redness will occur and this is the desired result. In some instances, moderate to heaving swelling will occur especially the upper and lower eyelids. This is normal.

Brown dots/carbon crusts will be visible for 3-10 days following the treatment. In some instances, they will flake off and be replaced with pink marks while the skin is regenerating. This could last up to 8 weeks. This is rare.

You must adhere to the aftercare advice. This is very important to reduce the risk of any post procedure infection. Avoid picking, plucking, knocking or rubbing the carbon crusts. This will hinder the healing process.

Be aware that any skin altering, medi aesthetic or cosmetic surgery, implants, injectables and weight gain may alter the Plasma Pen look. The best is to be patient and let it heal properly.

What area are you interested in having treated?

Have you had Plasma Skin Tightening before?

YesNo

If yes, were you happy with the result?

YesNo

Where did you have treated?

Are you pregnant or nursing (last 9 months)

YesNoOther

Do you have allergies to any kind of medicine, food, skincare products ingredients, or latex gloves, plasters etc? If so, please list and explain.

Have you ever had a reaction to a local/topical anesthetic such as Benzocaine, Lidocaine, Tetracaine, or epinephrine?

YesNo

Are you allergic to aloe, silver, colloidal silver or SPF? If so, which ones?

YesNo

Do you have an allergy to penicillin?

YesNo

Have you had a hysterectomy in the last 6 months or do you intend to have one in the next 12 weeks?

YesNo

Do you have a hormonal imbalance in the last 9 months?

YesNo

Are you taking any medications or supplements?

YesNo

If yes, please explain.

Do you suffer from infectous or acute/chronic diseases?

YesNo

Do you suffer from high or low blood pressure?

YesNo

Do you have circulatory issues or Ischemic Tissue or Thrombosis?

YesNo

Do you suffer from epilepsy, dizziness, fainting attacks or seizure related conditions?

YesNo

Are you taking anticoagulant (blood thinning medications) such as Heparin, Warfarin (Coumadin), Apixaban, Dabigatran, Edoxaban or Rizareoxaban)?

YesNo

If yes, please explain.

Do you have Lupus, MS, Scleroderma, Shingles, Psoriasis etc?

YesNo

If yes, please explain

Do you have Asthma or pulmonary problems like Emphysema, COPD or bronchitis?

YesNo

If yes, please explain

Do you have heart problems or conditions? Do you have angina? Pacemaker? If yes, please explain,

Do you suffer from a blood disorder?

YesNo

Do you suffer from kidney or liver disease?

YesNo

Do you suffer from kidney or liver disease?

YesNo

Have you had an organ transplant?

YesNo

Do you suffer from Herpes Simplex Virus (cold sores)

YesNo

Do you have prosthesis implants, plates or pins in the area being treated?

YesNo

Do you have or are you planning to have Botox, fillers, laser treatments, chemical peels, micro-needling, permanent makeup or cosmetic surgery in the near future? Have you had anything done in the last 3 months?

If yes, do you have issues with healing? Please explain.

Are you currently wearing lash extensions Or have fake lashes on?

YesNo

Have you had Laser Eye surgery in the last three months?

YesNo

Do you have a visual impairment, corneal abrasion or retinal detachment?

YesNo

If yes, please explain.

Do you suffer from Glaucoma, Dry Eyes/Conjunctivitis?

When was the last time you were in the sun, used a tanning cream, spray or gel? (Please be honest)

Are you in good mental and physical health?

Do you have plans to go in the sun? If yes, please explain

Are you currently under the influence of drugs or alcohol? Yes or no

Do you suffer from body dysmorphia? Yes or no

Are you aware that, post-treatment, you may not look your best for the next few days. There will be a period of downtime where you may experience minor discomfort, redness and swelling and you are expected to follow the after care regimen? Yes or no? If no, please explain.

Is there anything else you would like to disclose or discuss ahead of your service?

What Fitzpatrick are you?

Fitzpatrick 1-Light/Pale White Always burns, never tansFitzpatrick 2-White/Fair Usually burns, tans with difficultyFitzpatrick 3-Medium White to Olive Sometimes mild burns, gradually tans to oliveFitzpatrick 4-Olive Dark Brown Very rarely burns, tans easilyFitzpatrick 5- Brown Dark Skin Very rarely burns tans very easilyFitzpatrick 6- Black, very dark brown to black Very rarely burns, tans very easily

What color are your eyes?

What is your natural hair color?

Do you have a lot of freckles on unexposed areas?

I understand that my Plasma Pen specialist will be in direct contact with me in relation to my service. This treatment involves the use of disposables. All equipment is sterilized before use, all surfaces involved in the process are protected, gloves will be worn at all times and my Plasma Pen will look to use medical asepsis conditions and no touch technique throughout. I hereby give written consent to the specialist who is fully trained and insured to carry out the treatment of choice as requested by me. I have read and fully understand the nature of this consult form.

I have the option for a patch test.

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Previous History

Eye Health

This section will help determine the coloring of your skin.