Plasma Skin Experts

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Plasma Skin Experts

Client Information, Indemnity & Consent Form
The information supplied below is strictly confidential and for professional use only.

Email *

Full Name *

Email *

Address *

City *

State *

Contact Number *

Occupation

Please provide your occupation as it helps us determine the potential impact on your downtime recovery

Date of Birth *

YYYY

How did you find out about us? *

Do you have any allergies? If yes, please write them below *

Which treatment are you interested in? Hot Plasma (Plasma Fibroblast) or Cold Plasma (Jet Plasma). *

Hot Plasma (Plasma Fibroblast)

Cold Plasma (Jet Plasma)

Required

Have you had a Hot Plasma (Plasma Fibroblast) or Cold Plasma (Jet Plasma) treatment in the past? If yes, please write either hot or cold and which areas *

Have you previously had any of the skin care modalities below?

There are more options to the right, make sure you scroll right ➡️

Within last 7 days

Within last 14 days

Within last 21 days

Within last 60 days

100+ days ago

Never

Botox

Dysport

Dermal Filler

Threads

HiFU

Morpheus 8

Chemical Peel

PRP

Microneedling

Fitzpatrick Scale *

The Fitzpatrick scale for skin typing is a widely used method of identifying the amount of pigment in a person's skin and tolerance to sun exposure.

If you do not know your Fitzpatrick skin type; please follow this link and answer the questions to work out your level: Fitzpatrick Skin Type Test

If you have trouble working out your Fitzpatrick Skin Type, please let us know & we can help you.

Type I

Type VI

MEDICAL INFORMATION

In order to perform your Plasma Fibroblast treatment with the best possible results, we ask that you tick the below applicable criteria:

Are you currently using any of the skin care products below?

There are more options to the right, make sure you scroll right ➡️

Using daily

Within last 7 days

Within last 21 days

Within last 60 days

100+ days ago

Never

Retinol

Roaccutane

Vitamin A (Oral or Topical)

Salicylic (BHA) Acid

Glycolicic (AHA) Acid

Contraindications

Contraindications are conditions that may be present, and are such that you would not be allowed to be treated with Plasma Fibroblast, unless you have written confirmation from your GP that it is safe to do so.

Current or history of cancer, especially malignant melanoma or recurrent non-melanoma skin cancer, or pre-cancerous lesions or after recovery from cancer till off medication for 6 months and have GP approval prior to commencing treatment

Any active infection

Diseases such as a history of recurrent Herpes Simplex, Systemic Lupus Erythematous or Porphyria

Use of photosensitive medication, and/or herbs that may cause sensitivity to such as, tetracycline or St. John’s Wart off

Immunosuppressive diseases including AIDS and HIV infection or use of immunosuppressive medications

Diabetes unless under control

History of bleeding coagulopathies or use of anticoagulants

History of heart disease (Angina, heart pacemaker, taking anti-coagulant drugs)

Surgery in the past 6 months

Alcohol Abuse

Drug Abuse

Breast feeding

Cuts and abrasions

Deep bruising

Epilepsy

Fever

High blood pressure

Low blood pressure

Taking blood thinning medication

History of keloid scarring

Cold sores (Either active or have a history)

Immediately after pregnancy

Liver disease and/or any medication that affects the liver function

Metal implants/plates or pins

Open wounds/ulcers/sores (on treatment area)

Pacemaker fitted

Phlebitis

Poor circulation (blood and lymph)

Pregnancy

Recent scarring to treatment area

Skin disorders

Thrombosis

Thyroid disease or other hormonal disorders

Other:

Areas of Application with Fibroblast treatment *

Please select all areas that you are having treated

Full Face

Forehead

Brow lift

Frown lines (11's or Bunny Ears)

Upper Eyes

Under Eyes

Crows Feet

Excess Ear Skin Tightening

Nose

Cheeks

Smile Lines (Nasolabial Folds)

Smile Lines (Marionette Lines)

Upper Lip (Lip Flip)

Lower Lip (Lip Flip)

Upper Lip (Smokers Lines)

Jawline

Jowls

Chin (Face)

Chin (Submental)

Neck

Chest

Tummy

Eye of Belly (Belly Button)

Scars

Acne Scarring

Wrinkle smoothing

Skin Tightening

Skin Resurfacing

Sunlight damaged skin (Actinic Precanceroses)

Age spots (lentiginos)

Other:

Required

A copy of your responses will be emailed to the address you provided.

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