Plasma fibroblast consent form

Date(Required)

Full Name(Required)

Date of Birth(Required)

Phone(Required)

Email(Required)

Your Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Occupation(Required)

How did you hear about us?(Required)

Would you like to be informed of our specials?(Required)

(Please ensure you have clearly supplied your email id & contact no. above)

Yes

What is plasma fibroblast therapy?

Plasma fibroblast therapy targets fibroblasts. These are collagen– and protein-producing cells in the dermis, the layer of skin just below your outermost skin layer. Fibroblasts play an important role in helping skin wounds heal as well as maintaining skin firmness and tightness. Plasma fibroblast therapy uses a pen-like device that discharges a high-frequency electric current to small areas of the skin. The plasma tip doesn’t directly touch the skin, but instead releases a targeted current just above the skin. The hot current creates small holes, or micro-injuries, in the skin’s layer.
According to a 2019 article published in the PMFA journal, the thermal disruption, or heat damage, from plasma fibroblast therapy:

• breaks down proteins in the skin
• encourages tissue regeneration
• stimulates fibroblast activity
• causes tissue contraction (tightening)

What are the benefits of plasma fibroblast therapy?

Plasma fibroblast therapy is a nonsurgical treatment that may be used to treat the following conditions:

• acne scars
• photoaging, including age spots.
• seborrheic keratosis
• Skin tag removal
• Mole removal
• Wart removal
• wrinkled skin, including the eyelids, neck, jawline, and above the lips.

Cosmetic specialists may also use plasma fibroblast therapy as an alternative to lip fillers to make the lips look fuller.

Does it work?

When plasma fibroblast therapy is performed in a safe, controlled environment, it can:

• improve skin texture
• offer mild-to-moderate skin tightening effects
• result in some degree of skin facial contour change

According to a 2014 article published in the journal Clinical, Cosmetic and Investigational Dermatology, the effects are expected to stimulate fibroblast production for up to 1 year after treatment.

What’s the procedure like?

While the procedure may vary slightly based on where you’re having the treatment, the basic steps typically include:

• Cleansing the skin and applying a topical anaesthetic (numbing) cream. You may need to wait about 30 minutes for the numbing cream to take effect.
• Treat the designated skin area with the plasma pen. The pen will create small arcs of microcurrents that make small scab-like dots on the skin.
• A professional will remove the numbing cream and apply a cooling gel to minimize the tingling and burning sensation whenever possible.
• The procedure usually takes about 30 to 60 minutes to perform.

Who’s a good candidate for this procedure?

The best candidates for this procedure are people with mild-to-moderate skin wrinkling concerns.
You shouldn’t receive plasma fibroblast therapy if you:

• are breastfeeding
• are pregnant
• have an allergy to topical anaesthetic preparations.
• have an infection at the treatment site
• are using isotretinoin for wrinkles or acne

In addition, if you have a history of keloids or hypertrophic scarring, it’s recommended that you approach plasma fibroblast therapy with caution.
It’s important to talk to a healthcare provider prior to the procedure to discuss your treatment goals and any potential concerns you may have given your overall health condition.

Is it safe and are there any side effects?

It’s very important that the healthcare provider performing the procedure establish realistic goals with you. While plasma fibroblast therapy can offer results, they aren’t likely to be as dramatic as a surgical procedure.
In addition, the procedure isn’t without side effects. Examples of side effects include:

• redness
• swelling
• mild hypopigmentation (light spots)
• mild hyperpigmentation (dark spots)
• skin peeling and crusting

Recovery

Once the procedure is completed, you can expect the small dots to scab over and fall off after about 1-2 weeks. Over the next couple of weeks, as your skin heals, it should appear tighter and firmer. Some people may see benefits from one treatment, while others may require three treatments before they see results.

Let your skin heal – to avoid scars

The tiny wounds which have been created, then develop a scab or crust. This looks like small brown/black spots all over the skin which has been treated. The key to scarring or not scarring is partly due to how you look after the scabs. To avoid scarring you need to:

• Keep the scabs clean by washing them in cool boiled water.
• Do not pick them – let them drop off, even though they’ll be very itchy!
• Don’t use anything which can tangle and tug them off.
• Once they’ve dropped off, make sure you protect the skin with high SPF for at least 1 month.

Don’t try this at home

Just because something is sold online doesn’t mean it’s safe. Some websites may sell pens that claim you can perform plasma fibroblast therapy at home. This is never a good idea. There are no controls on how these pens are made, and they have the potential to cause significant harm, such as facial burns.

Checkbox(Required)

I have read all above and understand the procedure.

Client Signature(Required)

CONSENT FORM & CONSULTATION

PLEASE READ CAREFULLY AND SIGN WHERE INDICATED, ONLY when you are happy to proceed. Ensure all points below have been discussed with your specialist. You are signing to state that you understand and accept these terms.

Terms of your treatment:

You have chosen a cosmetic procedure that is not medically necessary.
Fibroblast Plasma lift is an art process, not an exact science and cannot guarantee an exact shrinkage result due to skin elasticity and individual healing process.
You may be required to return for additional treatments before your overall procedure is deemed complete. The payment for any additional work, are applicable, Additional treatments, cannot be performed until after 4-8 weeks from date of initial treatment. This is in order to allow the initially treated area to heal fully.
Your specialist will use a treatment plan to record the areas you have chosen, Numbing anaesthetic will be used on treatment area, as well as pre and post treatment photographs. This information will be held securely in your consultation record.
The skin type of every client is different, and the healing process may lead to some discoloration of the skin. If exposed to sun while healing.
After each treatment some swelling, or redness may occur. In some cases there may be extreme swelling. Your specialist will give you appropriate advice to help reduce this risk. Throughout the treatment you may experience some discomfort, but your specialist will reassure you throughout and endeavour to make you feel comfortable.
Since the treatment includes small burns to the skin, you may experience the smell of charring. This is perfectly normal.
You must adhere to the specialist’s aftercare advice given to you following your treatment. This is very important and will reduce the risk of post procedural infection upon leaving the clinic. You must let the treated area heal properly. Avoid picking, plucking, knocking as this will hinder the healing process and could make the treatment appear uneven thus requiring further work.

TO BE COMPLETED BY THE CLIENT

TREATMENT AREA:

Photographic consent(Required)

I consent to photographs being taken BEFORE, DURING, and AFTER my procedure. I agree to these being stored with my case file and used only with my written consent for promotional purposes.

I ALSO CONSENT TO THE USE OF MY PHOTOGRAPHS AND VIDEO FOOTAGE FREE OF CHARGE FOR MARKETING PURPOSES.(Required)

Yes

Signature(Required)

I understand that my specialist will be in direct contact with me in relation to the plasma pen treatment. This treatment involves the use of a disposable probe. All other equipment is sterilized before use, all surfaces involved in the process are protected and gloves will be worn at all times by the specialist during the treatment.
I hereby consent to receiving a plasma pen treatment. My specialist has explained the terms and conditions of the treatment and I have fully understood these. I hereby give written consent to the specialist who is carry out the treatment of my choice as requested by me on this consent and treatment agreement.

MEDICAL FORM (To be completed by the client)

Gender(Required)

Male

Female

Have you received any skin tightening treatment before?(Required)

Yes

How long ago was your treatment?(Required)

What procedure did you receive?(Required)

At what clinic did you receive the treatment?(Required)

Were you happy with the result?(Required)

Yes

Please explain the reasons why

Are you over the age of 18?(Required)

Yes

Are you pregnant?(Required)

Yes

Are you under the influence of alcohol or drugs?(Required)

Yes

Are you in good health?(Required)

Yes

MEDICAL CONDITIONS Please answer YES or NO to the following questions.

These details will then be discussed (in confidence) with your specialist.(Required)

Yes

Details (if yes)

Do you feel fit and well enough to have a Plasma pen lifting procedure today?(Required)

Yes

Details (if yes)

Do you have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster, etc?(Required)

Yes

Details (if yes)

Are you currently taking any medication?(Required)

Yes

Details (if yes)

Do you have or are you planning to have any injectables, fillers or chemical peels in the near future?(Required)

Yes

Details (if yes)

Do you suffer from epilepsy?(Required)

Yes

Details (if yes)

Do you knowingly suffer from any infectious diseases?(Required)

Yes

Details (if yes)

Do you suffer from high or low blood pressure?(Required)

Yes

Details (if yes)

Do you suffer from diabetes?(Required)

Yes

Details (if yes)

Do you have any respiratory problems?(Required)

Yes

Details (if yes)

Do you suffer from, or have any problems with scars healing?(Required)

Yes

Details (if yes)

Do you suffer from dizziness or fainting attacks?(Required)

Yes

Details (if yes)

Do you suffer from HIV/AIDS?(Required)

Yes

Details (if yes)

Do you suffer from heart problems?(Required)

Yes

Details (if yes)

Do you suffer from Hepatitis?(Required)

Yes

Details (if yes)

Do you suffer from any Lymphatic problems?(Required)

Yes

Details (if yes)

Do you suffer from Haemophilia?(Required)

Yes

Details (if yes)

Do you suffer from skin problems (i.e. Eczema, Psoriasis)?(Required)

Yes

Details (if yes)

Do you have an allergy to penicillin?(Required)

Yes

Details (if yes)

Do you suffer from Keloid scarring?(Required)

Yes

Details (if yes)

If you suffer from any of the above it is important that you notify your specialist who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health.

1st Lady health & beauty CONSULTATION RECORD

Notes to discuss.(Required)

Initial(Required)

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 medial history it is my responsibility to inform my specialist.

Client Signature(Required)

Specialists Signature(Required)

TREATMENT PLAN

This part of the consultation record is to be completed by the specialist in order to record important elements of the treatment. This form must be kept with the clients Medical and Consent forms.

Clinical report(Required)

I, the specialist, 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 treatment. Aftercare advice has been presented to the client.

Specialists Signature(Required)

Please ask your client to read, understand and sign the following prior to treatment: I, the client, agree with all points listed and discussed, and wish to proceed as recorded. I participated fully in the decision for selected area or areas intended for my treatment. I hereby agree to follow after advice.

Client Signature(Required)

To be completed by the client after filling above form:

My procedure has been explained and I am satisfy and I have been given the opportunity to discuss any immediate concerns with my specialist.
I fully understand my aftercare instructions and have my aftercare advice.

Client Signature(Required)

Specialists Signature(Required)

+61 459 627 100

Please Call / Text For Appointment

Subscribe Now and Get Discount 10%