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PLASMA FIBROBLAST WAIVER OF LIABILITY

May 27, 2025

Plasma Soft Surgery Treatment is a procedure that can only be performed by a specifically trained and qualified specialist therapist. Using approved equipment to shrink the skin using a sterile disposable probe.
 
Before carrying out the treatment, you are required to complete and sign this consultation record, thus giving your absolute consent to treatment. Additionally, you will need to disclose your full medical history, which will determine whether you are a suitable candidate for the proposed treatment. If the specialist does not think you are suitable for the treatment, this will not be carried out.
 
Your specialist will discuss the procedure in full, including what it will involve, discuss the benefits, explain any risks, the healing process and advise upon any further treatment if / where necessary. You will then be provided with written aftercare information for you to keep and refer to during the subsequent healing process.
 
Contra-indications will be recorded on this consultation form, which will be used as a reference for future visits.
 
It is important you clearly mark any areas of this form you wish to have clarified or discuss further. It is ultimately YOUR responsibility to ensure you understand in full the procedure and the expected outcomes before treatment commences.
 
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: oYou have chosen a cosmetic procedure that is not medically necessary.
 
-Plasma pen lifting 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, (if applicable), will be agreed prior to the treatment commencing. Depending upon area of treatment, 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, anaesthetic used, probe used 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 discolouration of the skin. (Microdermabrasion or skin rejuvenation) may be advised, after the healing process is complete.
 
-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.
 
oSince 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 or knocking as this will hinder the healing process and could make the treatment appear uneven thus requiring further work.
 
-Be aware that skin altering procedures such as plastic surgery, implants, injectable’s and weight gain may alter the look

-By signing and initialing this waiver of liability form you are legally agreeing and adhering to the following terms & conditions:
-Results are never 100% guarenteed & we cannot control how your body responds to any treatment whatsoever. We are 100% FREE of ANY liability whatsoever associated with your personal results from any treatment preformed at House of Wax LLC becaus ethis is an elective cosmetic procedure you are selecting at your OWN RISK. House of Wax will NOT be slandered on any public forum WHATSOEVER following ANY procedure or service preformed at the salon. All concerns & any possible dissatisfaction MUST be addressed with your artist personally & NOT taken to social media of any form. Slander & libel are serious offenses & legal action will be taken if any violations of any terms listed on this waiver are violated.
House of Wax LLC is not responsible for ANY reactions/risks associated with any treatments preformed because YOU ARE SELECTING THIS SERVICE AT YOUR OWN RISK & YOU ARE RESPONSIBLE FOR RESEARCHING & KNOWING RISKS & SIDE EFFECTS BEFOREHAND & ARE LEGALLY SIGNING OFF THAT HOUSE OF WAX LLC WILL NOT BE HELD FINANCIALLY RESPONSIBLE FOR ANY OUTCOME WHATSOEVER.

May 27, 2025



DO YOU AGREE TO ALL TERMS LISTED ON THIS WAIVER?

 

First Clients Name
First Name*
Middle Name
Last Name*
Phone*
First Clients Date of Birth*
Date of Birth
First Clients Signature*
Second Clients Name
First Name*
Middle Name
Last Name*
Clients Date of Birth*
Date of Birth
Third Clients Name
First Name*
Middle Name
Last Name*
Clients Date of Birth*
Date of Birth
Fourth Clients Name
First Name*
Middle Name
Last Name*
Clients Date of Birth*
Date of Birth
Fifth Clients Name
First Name*
Middle Name
Last Name*
Clients Date of Birth*
Date of Birth
Sixth Clients Name
First Name*
Middle Name
Last Name*
Clients Date of Birth*
Date of Birth
Seventh Clients Name
First Name*
Middle Name
Last Name*
Clients Date of Birth*
Date of Birth
Eighth Clients Name
First Name*
Middle Name
Last Name*
Clients Date of Birth*
Date of Birth
Ninth Clients Name
First Name*
Middle Name
Last Name*
Clients Date of Birth*
Date of Birth
Tenth Clients Name
First Name*
Middle Name
Last Name*
Clients Date of Birth*
Date of Birth
Clients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email*
Confirm Email*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card
Driver's License / ID Card Number*
Issuing State*
Medical History
Do you feel fit & well enough to receive the plasma pen fibroblast procedure today?*
No
Yes
Do you have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster etc?*
No
Yes
Are you currently taking any medication?*
No
Yes
Do you have any imminent holiday plans?*
No
Yes
Do you have or are you planning to have any injectables, fillers or chemical peels in the near future?*
No
Yes
Do you suffer from epilepsy?*
No
Yes
Do you knowingly suffer from any infectious diseases?*
No
Yes
Do you suffer from a high or low blood pressure?*
No
Yes
Do you suffer from diabetes?*
No
Yes
Do you have any respiratory problems?*
No
Yes
Do you suffer from, or have any problems with scars healing? History of Keloids?*
No
Yes
Do you suffer from dizziness or fainting attacks?*
No
Yes
Do you suffer from HIV/AIDS?*
No
Yes
Do you suffer from heart problems?*
No
Yes
Do you suffer from Hepatitis?*
No
Yes
Do you suffer with any Lymphatic problems?*
No
Yes
Do you suffer from Hemophilia?*
No
Yes
Do you suffer from skin problems (i.e. Eczema, Psoriasis)?*
No
Yes
Do you have an allergy to penicillin?*
No
Yes
Do you agree to proceed with this treatment at your OWN RISK & release House of Wax LLC of ANY financial or medical liability whatsoever & agree to not slander any artist associated with this establishment?*
No
Yes
Add ANY notes to discuss
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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