Jet Plasma Medical History and Consent

Medical History and Consent
Full Name
Date

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
How were you referred to our facility
Current Medications (please list):
Have you taken Accutane within the last year?

YesNo
Allergies please list
Please Read Carefully - Have you had or do you currently have any of the following? Indicate YES with an (X)
Type a question

CancerCold SoresContact LensesLatex Sensitivity/AllergyEpilepsyTattoo/Permanent MakeupHigh or Low Blood PressureHemophiliaProblems with HealingBotox TreatmentChemical PeelsLaser ResurfacingPlasma Pen TreatmentCosmetic SurgeryHeart ConditionDiabetesDermatitis/EczemaHypoglycemiaHepatitisHIV / AIDSKeloid ScarsThyroid DiseaseIron Deficient/AnemicInjectable FillersGlycolic AcidPregnant/NursingPacemaker
* 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 by 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 that Aubrey James, Pro Plasma Esthetic, Lashes, Locks & Lips only provides beauty services; There is no medical treatment involved. Plasma Pen Treatment is an art - not an exact science - and cannot guarantee an exact shrinkage result due to skin elasticity and individual healing process. Please be advised results may be different from one individual to another.*
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2. I understand that I may be required to return for additional treatments before the overall procedure 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 after 6-8 weeks from the initial treatment date to allow sufficient healing time.*
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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 hereby agree to hold Aubrey James Pro Plasma Esthetic Lashes Locks Lips their agents and employees free from any and all claims or suits for damage for injuries or complications resulting from any beauty services provided by Aubrey James Pro Plasma Esthetic Lashes Locks Lips I understand that any spot removals skin revision work performed may result in minor scarring and or loss or gain of natural skin pigment.*
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4. The skin type of every client is different and the healing process may lead to some discoloration of the skin It is imperative that the Aftercare provided is followed Microdermabrasion or skin rejuvenation may be advised after the healing process is complete.*
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5. I understand that the taking of before and after photographs of the said procedures is a condition of such procedure. I grant permission for the use of the photographs, or electronic media images as identified, in any presentation of all kinds.*
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6. I have received pre and post procedure instructions with the care kit and will strictly adhere to them I understand that my failure to do so may jeopardize my chances for a successful procedure outcome.*
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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.*
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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.*
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I, the client, agree with all points listed and discussed, and wish to proceed as recorded. I participated fully in the decision for the selected area or areas intended for my Plasma Pen Treatment. I certify 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.
Clients Full Name PRINTED*
Client Signature*

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Treatment Agreement I, the trained technician, confirm 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 Plasma Pen Treatment. Aftercare advice has been verbally presented to the client and written instructions will be provided.
Technician Signature

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