PLASMA PEN CONSENT FORM

PLASMA PEN CONSENT FORM

YOUR PLASMA PEN CONSULTATION RECORD Plasma Pen is a procedure that can only be performed by a specifically trained and qualified specialist technician using approved equipment to shrink the skin using a sterile disposable probe. Your specialist technician is trained, qualified by Plasma Pen, has certification and is fully insured. Before carrying out the treatment you are, as a patient, required to complete and sign all relevant areas of this consultation record thus giving your absolute consent to treatment. Additionally, you will need to disclose your full medical history as that will determine whether you are a suitable candidate for the proposed treatment. If the specialist does not think you are suitable for the treatment, then your treatment cannot and will not be carried out. Your specialist will discuss your procedure with you, in full, including what it will involve and the likely benefits. Realistic expectations will be agreed and they will explain any risks, the healing process and will then advise you upon any further treatment you may require if/where necessary. You will then be provided with written aftercare information for you to keep and refer to during the subsequent healing process and it is essential you follow these instructions. Any contra-indications will be recorded on this consultation form and will be used as a reference for any future visits. It is important that you clearly mark any areas of this form that you wish to have clarified or discussed further. It is ultimately YOUR responsibility to ensure that you understand, in full, the Plasma Pen procedure and the expected outcomes BEFORE your treatment commences.

PLEASE READ ALL OF THE FOLLOWING CAREFULLY AND SIGN, WHERE INDICATED, when you are happy to proceed. You must ensure that all the points below have been discussed with your specialist t. You are signing to state you understand and accept the terms of your treatment.

TERMS OF YOUR TREATMENT:
1. You have chosen an elective cosmetic procedure that is not medically necessary

2. “Fibro blasting” with Plasma Pen is an artistic process - not an exact science - and it cannot guarantee an exact shrinkage result due to individual skin elasticity, the individual healing process and a range of other factors

3. Some results can be cumulative for optimal effects to be achieved and you may be required to return for additional treatments before your overall procedure is deemed complete. The payment for any additional work, if applicable, will be agreed with you prior to your treatment commencing

4. Depending upon the area of your treatment, additional treatments cannot usually be performed until 12 weeks after the date of your initial treatment. This is in order to allow the area treated initially to fully heal and for the full benefit of Plasma Pen to be apparent

5. Your specialist will use a treatment plan to record the areas that you have chosen, the anaesthetic used, the probe used as well as pre and post treatment photographs. This information will be held in your consultation record.

6. The skin type of every client is different and the healing process may in rare cases lead to some discoloration of the skin. Microdermabrasion, skin rejuvenation or other relevant treatment may thus be advised after the healing process is complete should this be the case

7. After each treatment some mild swelling or redness may occur which is completely normal. In some rare cases there may be extreme swelling. Your specialist will give you appropriate advice and aftercare technique to help reduce this

8. During your treatment you may experience some minor discomfort depending on the area being treated. Your specialist will reassure you throughout to make you feel comfortable

9. Since the treatment includes controlled micro traumas to the skin, you may experience the smell of plasma reacting with the skin surface during your treatment. This is perfectly normal

10. You must adhere to the specialist’s aftercare advice given to you following your treatment. This is very important as it will reduce the risk of post-procedural infection upon leaving the clinic. You must let the treated area heal properly. Avoid picking, plucking or knocking as this will hinder the healing process and could make the treatment appear uneven thus requiring further work. Your aftercare regime can make a huge difference to your ultimate results

Please be aware that any subsequent skin altering procedures such as plastic surgery, implants, injectables and weight gain may alter the Plasma Pen look.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.