Date:
Month Day Year
Date
Full Name:
Address:
Telephone:
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Email:
example@example.com
DOB:
Introduction: Plasma Pen is a non-invasive treatment that will be performed using CE/TGA approved (FDA pending) approved equipment and best practices safety and hygiene techniques to shrink, tighten, lift and rejuvenate the skin using a sterile disposable probe. Your specialist is trained and qualified by Plasma Pen, with full certification and insurance.
Before carrying out the treatment, YOU, as a client are required to complete and sign all relevant areas of this consultation record to give your absolute consent to the treatment. You will need to disclose your full medical history to determine whether you are a suitable candidate for Plasma Pen. If the specialist does not think you are suitable, then the treatment cannot be performed.
She will discuss your Plasma Pen treatment with you, in full, including what healing, recovery and downtime will be involved and the anticipated benefits. Realistic expectations will be agreed and any risks will be discussed. She will also discuss any further treatments needed to achieve the desired outcome. You will receive a separate aftercare form for you to read, sign and keep for your short and medium term healing process. It is absolutely essential you follow these instructions fully.
This treatment is elective and not medically necessary.
"Fibroblasting” with the Plasma Pen is an artform, not a direct science. It cannot always guarantee a measured shrinkage result due to individual skin elasticity, healing process based on age, health and lifestyle.
Results are accumulated over time and if multiple treatments are performed. The payment for additional treatments, if applicable will always be agreed upon prior to your treatment commencing
Additional treatments will not be performed until 12 weeks after the date of your initial treatment in order to allow for proper healing.
Photographs are required BEFORE, DURING and AFTER the treatment. I hereby grant that my photographs will be stored with my file. I consent that my photographs be used for advertising, marketing and social media purposes..
Every client is different and the healing process will vary. In RARE cases, there may be discoloration to the skin.
There may be minor discomfort depending on the area being treated.
The treatment includes delivering a highly controlled, precise and predictable micro-trauma to the surface of the skin. Plasma gas is completely safe. We work above the skin. We do not cause or leave any wound open. We do not damage the surrounding tissue and there is no risk of infection though you may experience a mild smell of charring during the treatment. This is normal.
Swelling and redness will occur and this is the desired result. In some instances, moderate to heaving swelling will occur especially the upper and lower eyelids. This is normal.
Brown dots/carbon crusts will be visible for 3-10 days following the treatment. In some instances, they will flake off and be replaced with pink marks while the skin is regenerating. This could last up to 8 weeks. This is rare.
You must adhere to the aftercare advice. This is very important to reduce the risk of any post procedure infection. Avoid picking, plucking, knocking or rubbing the carbon crusts. This will hinder the healing process.
Be aware that any skin altering, medi aesthetic or cosmetic surgery, implants, injectables and weight gain may alter the Plasma Pen look. The best is to be patient and let it heal properly.
What area are you interested in having treated?
Previous History
Have you had Plasma Skin Tightening before?
Yes No
If yes, were you happy with the result?
Yes No
Where did you have treated?
Are you pregnant or nursing (last 9 months)
Yes No Other
Do you have allergies to any kind of medicine, food, skincare products ingredients, or latex gloves, plasters etc? If so, please list and explain.
Have you ever had a reaction to a local/topical anesthetic such as Benzocaine, Lidocaine, Tetracaine, or epinephrine?
Yes No
Are you allergic to aloe, silver, colloidal silver or SPF? If so, which ones?
Yes No
Do you have an allergy to penicillin?
Yes No
Have you had a hysterectomy in the last 6 months or do you intend to have one in the next 12 weeks?
Yes No
Do you have a hormonal imbalance in the last 9 months?
Yes No
Are you taking any medications or supplements?
Yes No
If yes, please explain.
Do you suffer from infectous or acute/chronic diseases?
Yes No
Do you suffer from high or low blood pressure?
Yes No
Do you have circulatory issues or Ischemic Tissue or Thrombosis?
Yes No
Do you suffer from epilepsy, dizziness, fainting attacks or seizure related conditions?
Yes No
Are you taking anticoagulant (blood thinning medications) such as Heparin, Warfarin (Coumadin), Apixaban, Dabigatran, Edoxaban or Rizareoxaban)?
Yes No
If yes, please explain.
Do you have Lupus, MS, Scleroderma, Shingles, Psoriasis etc?
Yes No
If yes, please explain
Do you have Asthma or pulmonary problems like Emphysema, COPD or bronchitis?
Yes No
If yes, please explain
Do you have heart problems or conditions? Do you have angina? Pacemaker? If yes, please explain,
Do you suffer from a blood disorder?
Yes No
Do you suffer from kidney or liver disease?
Yes No
Do you suffer from kidney or liver disease?
Yes No
Have you had an organ transplant?
Yes No
Do you suffer from Herpes Simplex Virus (cold sores)
Yes No
Do you have prosthesis implants, plates or pins in the area being treated?
Yes No
Do you have or are you planning to have Botox, fillers, laser treatments, chemical peels, micro-needling, permanent makeup or cosmetic surgery in the near future? Have you had anything done in the last 3 months?
Botox Fillers Laser Treatments Chemical Peels Microneedling Cosmetic Surgery Permanent Make up
If yes, do you have issues with healing? Please explain.
Eye Health
Are you currently wearing lash extensions Or have fake lashes on?
Yes No
Have you had Laser Eye surgery in the last three months?
Yes No
Do you have a visual impairment, corneal abrasion or retinal detachment?
Yes No
If yes, please explain.
Do you suffer from Glaucoma, Dry Eyes/Conjunctivitis?
When was the last time you were in the sun, used a tanning cream, spray or gel? (Please be honest)
Do you have plans to go in the sun? If yes, please explain
Are you in good mental and physical health?
Are you currently under the influence of drugs or alcohol? Yes or no
Do you suffer from body dysmorphia? Yes or no
Are you aware that, post-treatment, you may not look your best for the next few days. There will be a period of downtime where you may experience minor discomfort, redness and swelling and you are expected to follow the after care regimen? Yes or no? If no, please explain.
Is there anything else you would like to disclose or discuss ahead of your service?
This section will help determine the coloring of your skin.
What Fitzpatrick are you?
Fitzpatrick 1-Light/Pale White Always burns, never tans Fitzpatrick 2-White/Fair Usually burns, tans with difficulty Fitzpatrick 3-Medium White to Olive Sometimes mild burns, gradually tans to olive Fitzpatrick 4-Olive Dark Brown Very rarely burns, tans easily Fitzpatrick 5- Brown Dark Skin Very rarely burns tans very easily Fitzpatrick 6- Black, very dark brown to black Very rarely burns, tans very easily
What color are your eyes?
What is your natural hair color?
Do you have a lot of freckles on unexposed areas?
I understand that my Plasma Pen specialist will be in direct contact with me in relation to my service. This treatment involves the use of disposables. All equipment is sterilized before use, all surfaces involved in the process are protected, gloves will be worn at all times and my Plasma Pen will look to use medical asepsis conditions and no touch technique throughout. I hereby give written consent to the specialist who is fully trained and insured to carry out the treatment of choice as requested by me. I have read and fully understand the nature of this consult form.
I have the option for a patch test.
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Previous History

Eye Health

This section will help determine the coloring of your skin.