Fibroblast Plasma Skin Tightening Intake Form

Name*

First NameLast Name

Gender*

Date of Birth*

Date of Birth

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address*

Please enter a valid email.

Phone Number*

Please enter a valid phone number.

Emergency Contact*

Full Name / Phone Number

Are you under the care of a physician?*

YesNo

If yes, please provide physician's name and contact information:

Are you taking any medications, including blood thinners, or undergoing any medical treatments?*

YesNo

If yes, please list all current medications:

Do you have any known allergies, including to makeup products, pigments or medications?*

YesNo

If yes, please specify your allergies & reactions:

Have you experienced any adverse reactions to previous cosmetic procedures or makeup products?*

YesNo

If yes, please describe:

Do you have a history of cold sores or herpes simplex virus?*

YesNo

If yes, please describe:

Are you currently pregnant, planning to become pregnant, or breastfeeding?*

YesNo

Have you recently undergone any skin treatments (e.g., chemical peels, laser therapy, microneedling)?*

YesNo

Are you currently using any topical skincare products with active ingredients (e.g., retinoids, acids, steroids)?*

YesNo

Procedure Overview

Plasma Fibroblast Treatment is a non-surgical, non-invasive procedure that targets sagging skin, wrinkles, and other imperfections. It uses a handheld device that creates a tiny plasma arc, causing controlled micro-injuries in the skin. These micro-injuries stimulate collagen and elastin production, leading to skin tightening and rejuvenation. The procedure typically takes 30-60 minutes, with results that can last several years, depending on factors like skin type, age, and lifestyle.

Potential Risks and Complications

I understand that there are risks and potential complications associated with Plasma Fibroblast Treatment, including but not limited to:

Immediate Reactions: Temporary redness, swelling, and discomfort in the treated area.
Pain or Discomfort: Mild to moderate pain during the procedure, which can be managed with a topical anesthetic.
Scabbing: Tiny crusts or scabs may form in the treated area and typically fall off within 5-10 days.
Hyperpigmentation or Hypopigmentation: Temporary or permanent changes in skin color, particularly in individuals with darker skin tones.
Scarring: Although rare, there is a risk of scarring, especially in individuals prone to keloids.
Infection: There is a risk of infection if aftercare instructions are not followed properly.
Uneven Results: The treated area may heal unevenly, requiring additional treatments.
Delayed Healing: Healing time may be prolonged, especially if aftercare instructions are not followed.
Allergic Reactions: Rare allergic reactions to the topical anesthetics or skincare products used during the procedure.
Swelling and Bruising: Swelling and bruising may occur and typically subside within a few days to a week.
Unsatisfactory Results: The final appearance may not meet your expectations, and further sessions may be needed to achieve the desired outcome.
Tingling or Numbness: Temporary tingling or numbness in the treated area, which usually resolves within a few weeks.

Pre-Treatment Instructions

Avoid Sun Exposure: Limit sun and tanning bed exposure for at least two weeks before the treatment to reduce skin sensitivity.
Discontinue Exfoliants: Stop using exfoliants like retinoids and acids one week before to prevent irritation.
Avoid Blood Thinners: If applicable, avoid blood-thinning medications or supplements 48 hours before, after consulting with your physician.
No Makeup or Skincare: Arrive with a clean face, free of makeup and skincare products.
Hydrate: Drink plenty of water in the days leading up to the treatment.
Consult Physician: Inform your provider of any medical conditions, medications, or allergies. Consult your physician if needed.
Avoid Alcohol and Caffeine: Refrain from alcohol and caffeine for 24 hours before to minimize bleeding and sensitivity.

Post-Treatment Care Instructions

Keep the Area Clean: Gently cleanse the treated area with a mild cleanser. Avoid harsh soaps and scrubbing.
Do Not Pick or Scratch: Let scabs or crusts fall off naturally to prevent scarring and infection.
Apply Healing Ointment: Use the provided ointment as directed to keep the area hydrated and aid healing.
Avoid Sun Exposure: Protect the area from sun for at least six weeks. Use broad-spectrum sunscreen with SPF 30+ daily.
Avoid Heat Exposure: Stay away from saunas, hot tubs, and intense heat for 48 hours post-treatment to avoid irritation.
No Makeup or Skincare Products: Do not apply makeup or skincare products until the area is fully healed.
Avoid Exercise: Refrain from strenuous exercise for 48 hours to minimize swelling and irritation.
Monitor for Side Effects: Watch for signs of infection, increased pain, or unusual reactions, and contact your provider if needed.
Healing Process: The area will appear darker initially and gradually lighten as it heals. Peeling and flaking should subside within 7-10 days.
Follow-Up Appointment: Schedule a follow-up in 4-6 weeks to assess results and discuss any necessary touch-ups.

Client Responsibilities

I agree to inform the provider of any changes in my health, medications, or allergies before the treatment.
I understand that it is my responsibility to follow all pre- and post-treatment care instructions provided by the provider.
I acknowledge that results may vary based on individual factors, including skin type, adherence to aftercare instructions, and personal health.
I understand that I should not seek medical treatment from another provider during the course of my treatment with this provider.

I have read and understood the information provided above, including the potential risks and complications associated with Plasma Fibroblast Treatment. I have had the opportunity to ask questions and have received satisfactory answers. I consent to the treatment and accept all risks and responsibilities associated with it. I understand that I may withdraw my consent at any time before the treatment without penalty.*

Todays Date*

Date

Cancelation Policy Form

We are committed to providing all of our clients with exceptional care in a timely manner. For this reason, we have instituted a 24 hour cancellation policy for all appointments.

We understand that sometimes life gets in the way and appointments need to be rescheduled or canceled. However, we kindly ask that you provide at least 24 hours' notice if you need to cancel or reschedule your appointment. This allows us to offer the time slot to another client who may be waiting for an appointment.

If you need to cancel or reschedule within 24 hours of your appointment, a fee of the service cost will be charged. If you do not show up for your appointment and do not provide any notice, the full cost of the service will be charged.

If you are late we reserve the right to cut your service, you will be charged for the service you booked not the cut service. If you are more than 15 minutes late and we do not have enough time to perform the service due to timing, you will be charged in full.

We appreciate your understanding and cooperation in following our cancellation policy. Our goal is to provide the best possible service to all of our clients, and this policy helps us achieve that goal by ensuring that our estheticians' time is used efficiently and effectively.

I have read this policy and understand that I need to provide at least 24 hours notice when rescheduling or cancelling an appointment. If I fail to contact the office at least 24 hours in advance, I will be charged the appropriate cancellation fee.*

Todays Date*

Date

Photo & Video Release Form

I hereby grant permission to RB Beauty Bar and its employees to take photographs or videos of me, my likeness, and my overall appearance during my visit/appointment.

I understand that the photographs and videos may be used for promotional and marketing purposes, including but not limited to social media, website, print materials, and other forms of marketing. I understand that RB Beauty Bar has the right to edit and use these photographs and videos as they see fit.

I also understand that I will not receive any form of compensation or financial renumeration from the use of these photographs or videos.

I also understand that once the photographs or videos are used, RB Beauty Bar has no control over the use of the images by third parties, who may also use the images for their own purposes.

I release and discharge RB Beauty Bar, its owners and employees from any and all claims, demands, or causes of action that I may have against them arising out of or in connection with the use of the photographs or videos.

I hereby acknowledge that I have read and fully understand the terms of this release and that I have had the opportunity to ask any questions that I may have before signing.

By signing this release, I certify that I am at least 18 years of age. If under 18 years of age, a parent or legal guardian must sign this release.

By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.*

Todays Date*

Date