Medical History and Consent

Medical History and Consent

Jet Plasma Treatments
Full Name*
Date*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How were you referred to our facility?
Current Medications (please list)*
Allergies (please list)*
High or Low Blood Pressure*
Contact Lenses*
Heart Condition*
Dermatitis / Eczema*
Cancer.*
Keloid Scars*
Diabetes*
Latex Sensitivity / Allergy*
Hemophilia*
Lash Extensions*
Epilepsy*
Problems with Healing*
Tattoo / Permanent makeup*
Chemical peels*
Cannot perform Jet plasma for 8 weeks after last Peel.
Botox Treatment If yes when*
*Cannot perform Jet plasma until 2 weeks after last Botox treatment
Injectable Fillers If so, when*
*Cannot perform Jet Plasma until 2 weeks after any injectable.
Laser Resurfacing*
Cannot perform Jet plasma for 8 -12 weeks after fully healed.
Plasma Pen Treatment (fibroblast)*
Cannot perform Jet plasma for 8 -12 weeks after fully healed.
Electrical implant with slow release*
Jet plasma cannot be performed.
Hyperpigmentation Melasma*
Cosmetic Surgery
***If you suffer from any of the above, it is important that you notify your technician so that they can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health.***
CANCELLATION POLICY
Treatment times are reserved for your booked time slot. A 25% non refundable fee(up to $75) on your booked service will be charged for no shows or any cancelations made within 24 hours of service appointments. Thank you for your understanding. (Any actual emergency that is out of your control, the fee may be applied to your next service.)
Client Signature*

Clear
Client's Full Name (PRINTED)*
Date: (M/D/Y)*

MonthDayYear
Date
Should be Empty: