DermaNu Plasma Skin Tightening Client History, Consultation, & Consent Form

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DermaNu Plasma Skin Tightening is a non-invasive, non-surgical cosmetic procedure performed by a licensed, skillfully trained plasma pen practitioner who uses a plasma pen device to rejuvenate the skin using plasma energy. This treatment eliminates excess tissue in the epidermis which causes wrinkles, scars, and sagging skin. The pen is held above the skin and a tiny plasma arc connects the tip of the device (electrode) to the surface of the epidermis. When exposed to plasma energy, the skin goes through the process of sublimation, the action of turning matter from a solid to a gas, bypassing the liquid stage. In other words, evaporating excess tissue without the application of heat. The sublimation effect causes an instant contraction of the tissue, eliminating wrinkles, sagging skin, stretch marks, skin tags, scars, age spots, and more. The plasma energy stimulates the fibroblast cells in the epidermis which produce new collagen in the skin. This advanced procedure revives natural levels of the collagen, hyaluronic acid and fibronectin needed for fresh youthful skin. A series of tiny yellow-brown spots called carbon crusts are strategically placed to attain the desired result. The skin around each dot tightens instantly. The carbon crusts gradually fall off on their own, 5-10 days after the treatment and the skin continues to contract for 6-8 weeks. Results last 2-5 years as you age, depending on your lifestyle. It is very safe, low-risk, and highly effective. As with most cosmetic treatments, a consultation with an experienced, trained practitioner prior to service, as well as a strict aftercare routine, is required to promote proper healing and to help you achieve the maximum results. Prior to starting the treatment, you are required to read through, initial and complete the consult record, thus giving absolute consent to treatment. Additionally, you agree to fully disclose your full medical history, which will allow determination as to if you are a suitable candidate to receive this treatment. During your face to face consultation, details of the treatment including procedure, benefits, risks, intended results, subsequent visits and after-care will be discussed to your full understanding. Additionally, aftercare will be discussed and provided. It is imperative to clearly mark and notate any area on this form you wish to discuss further, prior to treatment. It is your responsibility to fully understand the procedure and expected outcomes before the treatment starts. Ensure all points below have been fully discussed and understood. When signing, you are stating that you understand and accept the terms of this treatment and consent to have the treatment performed by a licensed Plasma Skin Tightening Practitioner.

Today’s Date *

YYYY

Full Name *

Date of Birth *

YYYY

Mobile Phone Number *

Treatment Area(s) desired *

Have you received any plasma skin tightening treatment before? If so, when and where did you receive the treatment? *

Are you pregnant or nursing? *

Yes

Have you had botox or filler in the treatment area in the last 30 days or plan to within 30 days? *

Yes

Are you currently using retinol or peeling products? *

Yes

Are you currently taking any blood thinning medications or medications that cause sun sensitivity such as Accutane? *

Yes

Do you have any allergies or sensitivities to topical anesthetics (lidocaine, benzocaine)? *

Yes

Do you suffer from hyperpigmentation? *

Yes

Have you had any cosmetic procedures or permanent makeup in the last 90 days? If so, please explain. *

Have you had microneedling, laser facial, microdermabrasion, or chemical peels in the last 30 days? *

Do you suffer from psoriasis, rosacea, eczema, keloid scars (raised/protruding), seborrheic dermatitis, erysipelas (streptococcal bacteria), lesions, impetigo, lupus, scleroderma or any skin condition? *

Do you suffer from HIV/AIDS, hepatitis, tuberculosis, high or low blood pressure, diabetes, epilepsy, respiratory problems, heart problems, infections, cancer or any other medical condition? *

I understand, post-treatment, I may not look my best for the next few days and may potentially experience some minor discomfort, redness and swelling. *

Yes

I understand that for the desired outcome, more treatments may be required, at least 8 weeks apart. *

Yes

I agree to return in 6 weeks for my follow up appointment where my treatment will be examined to confirm proper healing, assess results, and have after photos taken. *

Yes

I agree to follow all aftercare instructions to reduce the risk of post-procedural infection, hyperpigmentation and potential scarring. *

Yes

I hereby release DermaNu and Jamie Lavender, and any and all persons representing the company, for all claims, demands, damages, actions, and cause of action arising out of the performance of these services. *

Yes

I confirm that I have read and understand the contents of this form and have answered truthfully. I have received no unrealistic warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure. *

Yes

Signature: *

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