Plasma Pen Consent Form

Your Name*

First NameLast Name

Which of the following best describes your skin type?*

Please indicate if any of the following contraindications pertain to you.

If any of the above apply to you, please provide more information below.

Are you currently taking any medication, including any over the counter remedies?*

YesNo

Do you knowingly have an infectious disease or other acute or chronic disease?*

YesNo

Do you suffer from uncontrolled, high or low blood pressure or any other kind of circulatory issues or deficiencies?*

YesNo

Do you suffer from dizziness, fainting attacks or any other seizure related condition?*

YesNo

Do you have any history of cancer?*

YesNo

Have you had any radiation or chemotherapy treatment?

YesNoNot applicable

Do you currently have, or have you ever been treated for any pigmentation disorders such as Melasma, Age Spots, Hyperpigmentation, Vitiligo and Solar Lentigines etc.?*

YesNo

Do you ever develop dark spots on the skin from wounds?*

YesNo

Are you taking, or have you applied any oral/topical steroids or corticosteroids in the last 6 months? This would include Hydrocortisone for Eczema.*

YesNo

Do you suffer from, or have any problems with scars healing? Do you suffer from keloid scarring, hypertrophic scarring or any other type of scarring?*

YesNo

Do you regularly use Retinol, Glycol, Salicylic Acid or benzoyl peroxide or any other exfoliating products devices (Clarisonic)?*

YesNo

Have you ever had any recent Permanent Make Up (PMU) or cosmetic treatment?*

YesNo

When was your PMU / cosmetic treatment treatment and did you experience any problems healing?

Do you have any corneal abrasion or retinal detachment?*

YesNo

Do you have any prosthetic implants or any plates or pins in the area being treated by Plasma Pen?*

YesNo

Is there any other ailment or reason not listed above you feel we should know about which could prevent us from delivering your Plasma Pen treatment?

Informed Consent

I understand post-treatment I may not look my best for the next few days and may potentially experience some minor discomfort, redness and swelling.
I understand that external healing time from a fibroblast treatment is 7-10 days and that full internal healing takes a period of 12 weeks.

I understand that in most cases post treatment redness, pigmentation and textural changes resolve within the first two weeks post treatment but that in rare cases it can take up to 12 weeks for these changes to resolve.

I do not have any allergies and never experienced allergic reactions to any kind of medications, foods or products (for example latex gloves).
I have never suffered an allergic reaction to any local/topical anesthetics.
I am not currently undergoing any medical treatment and/or have received any medical treatment within the last 6 months?
I acknowledge that this is an elective procedure at my request.
I certify that I have listed all medications/medical procedures/ medical disorders.
I understand that Fibroblasting with Plasma Pen cannot guarantee the exact outcome of this procedure and results may vary from client to client.
I grant consent to photographs being taken BEFORE, DURING and AFTER my Plasma Pen procedure.
I certify I have received written post treatment instructions.
I agree to follow all aftercare instructions reduce the risk of post-procedural infection, hyperpigmentation and potential scarring.
I agree to contact Faces Clinical Skincare with questions or concerns pre or post treatment.
I confirm I have fully read, understood and completed this Medical Conditions and Informed Consent Form and that the procedure known as Plasma Pen/Fibroblast has been fully explained to me.
I have had the opportunity to ask questions about the treatment and that my questions have been answered.
I understand the importance of fully revealing my accurate and complete medical history.
I understand that withholding any medical information may be detrimental to my health and safety both during and after my procedure and I confirm that I have not withheld any medical information.
I understand that if there is any change in my medical history it is my responsibility to inform my technician.
I understand that for the desired outcome several treatments may be required, and this has been explained to me.
I also understand no guarantee has been given as to what the outcome of treatment may or may not be and that there are no refunds on services provided.
By my signature I affirm that I am at least 18 years old and freely give my informed consent to receiving treatment.

Today's Date*

Date

Your Signature*