AGEJET CLIENT ASSESSMENT AND CONSENT FORM

AGEJET CLIENT ASSESSMENT AND CONSENT FORM

Client Consultation Form
Client Details
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Sex
Date of birth*

DayMonthYear
Date
Mobile Telephone No*
Email*
example@example.com
Visit Information
Skin area & type of concern
Age & cause of indication
Previous treatments
Medical History
Do you have a history of?

Cold SoresBleeding DisorderEasy BruisingSmokingSkin Injuries
Any allergies - skin, medication or anaesthetic related?Yes No
If yes, please specify: Allergies
Are you taking any medication or herbal preparations?
Daily alcohol consumption
Are you using skin bleaching agents or exfoliants?
Do you have or have had any dermatological condition?
Fitzpatrick Skin classification:
Are you going on holiday soon?
Do you have any pets at home?
Contraindication assessment for AgeJet™ Treatment

Indication

	Yes	No
Have you been considered unfit for general surgery?
Do you suffer from keloid scar formation?
Do you currently have an active skin or other infection?
Have you been on oral retinoids during the last 6 months? e.g., Roaccutane
Is there any broken skin in the treatment area?
Are you the pregnant or breastfeeding?
Is the treatment area tanned? (Including artificial tanning)
Do you suffer with any inflammatory skin condition?
Do you have an internal electronic device e.g., pacemaker?
Do you suffer from Vitiligo?
Have you regularly been applying topical steroids to the area to be treated

Client Consent
I understand that the AgeJet™ is intended for the treatment of a variety of skin related conditions related to aging, sun damage, injury and dermatological conditions. These include wrinkles and rhytides, superficial skin lesions, actinic keratosis, viral papillomata, seborrhoeic keratosis and acne scars.

AgeJet™ uses nitrogen plasma to deliver heat into the skin, which in turn results in initial skin tissue contraction. This is followed by a resurfacing of the epidermis and longer-term skin remodelling. The clinical results may vary.

I understand that there is likely to be short term effects such as reddening, mild burning sensation, and temporary discoloration of the skin followed by a fine peeling (dusting) as the outer layer of the skin repairs. There is also a potential risk of side effects such as infection, scarring and permanent or transient discoloration. These effects have all been fully explained to me. I understand there are other options for treatment available for my skin condition.

I have been shown photographs of the typical patient recovery progression and I have read, understood and have been given a copy of AgeJet™ Patient Guide including pre and post treatment recommendations. I have fully discussed the treatment, contraindications, AgeJet™ Patient Guide, and my expected healing time with my treatment provider, and have had all questions answered to my satisfaction.

I understand that my treatment provider will treat me in accordance with one or more of the treatment settings listed below:

Treatment Protocol

	Area of skin to be treated
Multiple treatment low energy (20 mm shot spacing) 0.5 J 50mm Spacers
Multiple treatment low energy (12mm spot size) 0.75J 42mm Spacers
High energy single treatment (8 mm spot size) 1.0 to 4.0 J 36mm Spacers
Double pass high energy (8mm spot size) 1.0 to 1.5 J 36 mm Spacers
Acne Scar (8mm spot size) 1.5 to 4.0 J 36 mm Spacers
Low energy irradiation for topical drug delivery (12mm spot size) 0.75 J 42mm spacers
Combination treatment with other modalities 0.5 to 1.5 J

The fee structure for the treatment with the AgeJet™ system has been fully explained to me and I understand the cost of the treatment and any standard follow-up care. I am choosing the non-invasive treatment for skin regeneration using the AgeJet™ system.
IDo Do Not give permission for photographs and other audio-visual and graphic materials to be used by the provider’s practice or by Cure Medical for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos.
I have read, and I understand this agreement and all my questions have been addressed and answered to my satisfaction. I agree to the terms of this agreement.
Client Name

First NameLast Name
Signature*

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Practitioner Name

First NameLast Name
Practitioner Signature*

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AGEJET CLIENT ASSESSMENT AND CONSENT FORM

Client Details

Visit Information

Medical History

Contraindication assessment for AgeJet™ Treatment

Client Consent