Medical Consultation Form
I acknowledge that this is an elective procedure at my request.
I certify that I have listed all medications/medical procedures/ medical disorders.
Fibroblasting with Plasma Pen cannot guarantee the exact outcome of this procedure, and results may vary from client to client.
I certify I have received written post-treatment instructions
I agree to follow all aftercare instructions to reduce the risk of post-procedural hyperpigmentation and potential scarring.
I agree to contact the service provider with questions or concerns post-treatment.
I confirm I have fully read, understood, and completed this Medical Conditions and Informed Consent Form and that the procedure known as Plasma Pen has been fully explained to me.
I have had the opportunity to ask questions about the treatment and that my questions have been answered. I understand the importance of fully revealing my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety both during and after my procedure, and I confirm that I have not withheld any medical information. I understand that if there is any change in my medical history, it is my responsibility to inform my technician.
I understand for the desired outcome, several treatments may be required, and this has been explained to me. I also understand no guarantee has been given as to what the outcome of treatment may or may not be. By my signature, I affirm that I am at least 18 years old and freely give my informed consent to receiving treatment.
May 30, 2023
It’s OK to apply ONE layer of Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin
that has been treated with Accutane®. Those who are currently taking Accutane® should be
directed to their dispensing physician.