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FIBROBLAST CONSULTATION RECORD

Fibroblast 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. The specialist is also fully insured.

Before carrying out the treatment, you are required to complete and sign this consultation record, thus giving your absolute consent to treatment. Additionally, you wil lneed to disclose your ful lmedical 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, explainany 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:

  • You have chosen a cosmetic procedure that is not medically necessary.
  • Fibroblast 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.
  • Sincethe 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 after care 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 fibroblast look.

Your specialist will follow guidelines as outlined in section 15 of the Local Government Act 1982. In addition to this, it is recommended that the trained specialist use aseptic conditions throughout the treatment.

PHOTOGRAPHIC CONSENT
I consent to photographs being taken BEFORE, DURING, and AFTER my procedure. I agree to these being stored with my case file and used only with my written consent for promotional purposes.

CONSENT
I understand that my specialist will be in direct contact with me in relation to the fibroblast treatment. This treatment involves the use of a disposable probe. All other equipment is sterilized before use, all surfaces involved in the process are protected and gloves will be worn at all times by the specialist during the treatment.

I hereby consent to receiving a fibroblast treatment. My specialist has explained the terms and conditions of the treatment and I have fully understood these. I hereby give written consent to the specialist who is a fully trained and insured specialist,tocarryoutthetreatment ofmy choiceasrequested bymeonthisconsentandtreatment agreement.

I, the client, agree with all points listed and discussed, and wish to proceed as recorded. I partici pated fully in the decision for selected area or areas intended for my fibroblast treatment. I hereby agree to follow after advice.

Today's Date: May 3, 2024

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Occupation:

Treatment Area:

Price Agreed:

Package:
PATCH TEST/WAIVER*

MEDICAL FORM

Have you received any skin tightening treatment before?*
No
Yes

If Yes, please answer the following questions: 


How long ago was your treatment?
Where you happy with the result?
Yes
No

What procedure did you receive?

If no, please explain the reasons why.

At what clinic did you receive the treatment?
Are you over the age of 18?*
No
Yes
Are you pregnant?*
No
Yes
Are you under the influence of alcohol or drugs?*
No
Yes
Are you in good health?*
No
Yes

MEDICAL CONDITIONS

Please answer YES or NO to the following questions. These details will then be discussed (in confidence) with your specialist. 


Do you feel fit and well enough to have a fibroblast procedure today?*
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 have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster etc?*
No
Yes

If so please list:
Are you currently taking any medications?*
No
Yes

If so please list:
Do you have any imminent holiday plans?*
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?*
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 Haemophilia?*
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 suffer from Keloid scarring?*
No
Yes

If you suffer from any of the above it is important that you notify your specialist who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. 


Notes to discuss:
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history it is my responsibility to inform my specialist.

FIBROBLAST TREATMENT PLAN 

This part of the consultation record is to be completed by the specialist in order to record important elements of the treatment. This form must be kept with the clients Medical and Consent forms.

PLEASE USE THIS FORM TO RECORD THE TREATMENT OF ONE AREA ONLY. All other treatments must be recorded on separatetreatment planforms. 


Treatment area(s) being completed:

Number of treatments recommended:
Treatment number: (only 4 treatments per 1 area)*
Indicate which scale:*

For first visit only: Following consultation with your client, what is the agreed treatment and how many visits will it take to achieve?

What is the predicted outcome and recommendations?

For 2nd and subsequent visits: CLIENT MUST COMPLETE A RECONSENT FORM. 


Were your clients expectations met?

Did the area heal as described?

What is the agreed objective for today's procedure?

What is the predicted outcome and recommendations?

Describe the treatment area including a description of the appearance of the skin:
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Occupation:

Treatment Area:

Price Agreed:

Package:
PATCH TEST/WAIVER*

MEDICAL FORM

Have you received any skin tightening treatment before?*
No
Yes

If Yes, please answer the following questions: 


How long ago was your treatment?
Where you happy with the result?
Yes
No

What procedure did you receive?

If no, please explain the reasons why.

At what clinic did you receive the treatment?
Are you over the age of 18?*
No
Yes
Are you pregnant?*
No
Yes
Are you under the influence of alcohol or drugs?*
No
Yes
Are you in good health?*
No
Yes

MEDICAL CONDITIONS

Please answer YES or NO to the following questions. These details will then be discussed (in confidence) with your specialist. 


Do you feel fit and well enough to have a fibroblast procedure today?*
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 have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster etc?*
No
Yes

If so please list:
Are you currently taking any medications?*
No
Yes

If so please list:
Do you have any imminent holiday plans?*
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?*
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 Haemophilia?*
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 suffer from Keloid scarring?*
No
Yes

If you suffer from any of the above it is important that you notify your specialist who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. 


Notes to discuss:
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history it is my responsibility to inform my specialist.

FIBROBLAST TREATMENT PLAN 

This part of the consultation record is to be completed by the specialist in order to record important elements of the treatment. This form must be kept with the clients Medical and Consent forms.

PLEASE USE THIS FORM TO RECORD THE TREATMENT OF ONE AREA ONLY. All other treatments must be recorded on separatetreatment planforms. 


Treatment area(s) being completed:

Number of treatments recommended:
Treatment number: (only 4 treatments per 1 area)*
Indicate which scale:*

For first visit only: Following consultation with your client, what is the agreed treatment and how many visits will it take to achieve?

What is the predicted outcome and recommendations?

For 2nd and subsequent visits: CLIENT MUST COMPLETE A RECONSENT FORM. 


Were your clients expectations met?

Did the area heal as described?

What is the agreed objective for today's procedure?

What is the predicted outcome and recommendations?

Describe the treatment area including a description of the appearance of the skin:
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Occupation:

Treatment Area:

Price Agreed:

Package:
PATCH TEST/WAIVER*

MEDICAL FORM

Have you received any skin tightening treatment before?*
No
Yes

If Yes, please answer the following questions: 


How long ago was your treatment?
Where you happy with the result?
Yes
No

What procedure did you receive?

If no, please explain the reasons why.

At what clinic did you receive the treatment?
Are you over the age of 18?*
No
Yes
Are you pregnant?*
No
Yes
Are you under the influence of alcohol or drugs?*
No
Yes
Are you in good health?*
No
Yes

MEDICAL CONDITIONS

Please answer YES or NO to the following questions. These details will then be discussed (in confidence) with your specialist. 


Do you feel fit and well enough to have a fibroblast procedure today?*
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 have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster etc?*
No
Yes

If so please list:
Are you currently taking any medications?*
No
Yes

If so please list:
Do you have any imminent holiday plans?*
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?*
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 Haemophilia?*
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 suffer from Keloid scarring?*
No
Yes

If you suffer from any of the above it is important that you notify your specialist who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. 


Notes to discuss:
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history it is my responsibility to inform my specialist.

FIBROBLAST TREATMENT PLAN 

This part of the consultation record is to be completed by the specialist in order to record important elements of the treatment. This form must be kept with the clients Medical and Consent forms.

PLEASE USE THIS FORM TO RECORD THE TREATMENT OF ONE AREA ONLY. All other treatments must be recorded on separatetreatment planforms. 


Treatment area(s) being completed:

Number of treatments recommended:
Treatment number: (only 4 treatments per 1 area)*
Indicate which scale:*

For first visit only: Following consultation with your client, what is the agreed treatment and how many visits will it take to achieve?

What is the predicted outcome and recommendations?

For 2nd and subsequent visits: CLIENT MUST COMPLETE A RECONSENT FORM. 


Were your clients expectations met?

Did the area heal as described?

What is the agreed objective for today's procedure?

What is the predicted outcome and recommendations?

Describe the treatment area including a description of the appearance of the skin:
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Occupation:

Treatment Area:

Price Agreed:

Package:
PATCH TEST/WAIVER*

MEDICAL FORM

Have you received any skin tightening treatment before?*
No
Yes

If Yes, please answer the following questions: 


How long ago was your treatment?
Where you happy with the result?
Yes
No

What procedure did you receive?

If no, please explain the reasons why.

At what clinic did you receive the treatment?
Are you over the age of 18?*
No
Yes
Are you pregnant?*
No
Yes
Are you under the influence of alcohol or drugs?*
No
Yes
Are you in good health?*
No
Yes

MEDICAL CONDITIONS

Please answer YES or NO to the following questions. These details will then be discussed (in confidence) with your specialist. 


Do you feel fit and well enough to have a fibroblast procedure today?*
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 have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster etc?*
No
Yes

If so please list:
Are you currently taking any medications?*
No
Yes

If so please list:
Do you have any imminent holiday plans?*
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?*
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 Haemophilia?*
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 suffer from Keloid scarring?*
No
Yes

If you suffer from any of the above it is important that you notify your specialist who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. 


Notes to discuss:
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history it is my responsibility to inform my specialist.

FIBROBLAST TREATMENT PLAN 

This part of the consultation record is to be completed by the specialist in order to record important elements of the treatment. This form must be kept with the clients Medical and Consent forms.

PLEASE USE THIS FORM TO RECORD THE TREATMENT OF ONE AREA ONLY. All other treatments must be recorded on separatetreatment planforms. 


Treatment area(s) being completed:

Number of treatments recommended:
Treatment number: (only 4 treatments per 1 area)*
Indicate which scale:*

For first visit only: Following consultation with your client, what is the agreed treatment and how many visits will it take to achieve?

What is the predicted outcome and recommendations?

For 2nd and subsequent visits: CLIENT MUST COMPLETE A RECONSENT FORM. 


Were your clients expectations met?

Did the area heal as described?

What is the agreed objective for today's procedure?

What is the predicted outcome and recommendations?

Describe the treatment area including a description of the appearance of the skin:
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Occupation:

Treatment Area:

Price Agreed:

Package:
PATCH TEST/WAIVER*

MEDICAL FORM

Have you received any skin tightening treatment before?*
No
Yes

If Yes, please answer the following questions: 


How long ago was your treatment?
Where you happy with the result?
Yes
No

What procedure did you receive?

If no, please explain the reasons why.

At what clinic did you receive the treatment?
Are you over the age of 18?*
No
Yes
Are you pregnant?*
No
Yes
Are you under the influence of alcohol or drugs?*
No
Yes
Are you in good health?*
No
Yes

MEDICAL CONDITIONS

Please answer YES or NO to the following questions. These details will then be discussed (in confidence) with your specialist. 


Do you feel fit and well enough to have a fibroblast procedure today?*
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 have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster etc?*
No
Yes

If so please list:
Are you currently taking any medications?*
No
Yes

If so please list:
Do you have any imminent holiday plans?*
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?*
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 Haemophilia?*
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 suffer from Keloid scarring?*
No
Yes

If you suffer from any of the above it is important that you notify your specialist who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. 


Notes to discuss:
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history it is my responsibility to inform my specialist.

FIBROBLAST TREATMENT PLAN 

This part of the consultation record is to be completed by the specialist in order to record important elements of the treatment. This form must be kept with the clients Medical and Consent forms.

PLEASE USE THIS FORM TO RECORD THE TREATMENT OF ONE AREA ONLY. All other treatments must be recorded on separatetreatment planforms. 


Treatment area(s) being completed:

Number of treatments recommended:
Treatment number: (only 4 treatments per 1 area)*
Indicate which scale:*

For first visit only: Following consultation with your client, what is the agreed treatment and how many visits will it take to achieve?

What is the predicted outcome and recommendations?

For 2nd and subsequent visits: CLIENT MUST COMPLETE A RECONSENT FORM. 


Were your clients expectations met?

Did the area heal as described?

What is the agreed objective for today's procedure?

What is the predicted outcome and recommendations?

Describe the treatment area including a description of the appearance of the skin:
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Occupation:

Treatment Area:

Price Agreed:

Package:
PATCH TEST/WAIVER*

MEDICAL FORM

Have you received any skin tightening treatment before?*
No
Yes

If Yes, please answer the following questions: 


How long ago was your treatment?
Where you happy with the result?
Yes
No

What procedure did you receive?

If no, please explain the reasons why.

At what clinic did you receive the treatment?
Are you over the age of 18?*
No
Yes
Are you pregnant?*
No
Yes
Are you under the influence of alcohol or drugs?*
No
Yes
Are you in good health?*
No
Yes

MEDICAL CONDITIONS

Please answer YES or NO to the following questions. These details will then be discussed (in confidence) with your specialist. 


Do you feel fit and well enough to have a fibroblast procedure today?*
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 have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster etc?*
No
Yes

If so please list:
Are you currently taking any medications?*
No
Yes

If so please list:
Do you have any imminent holiday plans?*
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?*
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 Haemophilia?*
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 suffer from Keloid scarring?*
No
Yes

If you suffer from any of the above it is important that you notify your specialist who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. 


Notes to discuss:
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history it is my responsibility to inform my specialist.

FIBROBLAST TREATMENT PLAN 

This part of the consultation record is to be completed by the specialist in order to record important elements of the treatment. This form must be kept with the clients Medical and Consent forms.

PLEASE USE THIS FORM TO RECORD THE TREATMENT OF ONE AREA ONLY. All other treatments must be recorded on separatetreatment planforms. 


Treatment area(s) being completed:

Number of treatments recommended:
Treatment number: (only 4 treatments per 1 area)*
Indicate which scale:*

For first visit only: Following consultation with your client, what is the agreed treatment and how many visits will it take to achieve?

What is the predicted outcome and recommendations?

For 2nd and subsequent visits: CLIENT MUST COMPLETE A RECONSENT FORM. 


Were your clients expectations met?

Did the area heal as described?

What is the agreed objective for today's procedure?

What is the predicted outcome and recommendations?

Describe the treatment area including a description of the appearance of the skin:
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Occupation:

Treatment Area:

Price Agreed:

Package:
PATCH TEST/WAIVER*

MEDICAL FORM

Have you received any skin tightening treatment before?*
No
Yes

If Yes, please answer the following questions: 


How long ago was your treatment?
Where you happy with the result?
Yes
No

What procedure did you receive?

If no, please explain the reasons why.

At what clinic did you receive the treatment?
Are you over the age of 18?*
No
Yes
Are you pregnant?*
No
Yes
Are you under the influence of alcohol or drugs?*
No
Yes
Are you in good health?*
No
Yes

MEDICAL CONDITIONS

Please answer YES or NO to the following questions. These details will then be discussed (in confidence) with your specialist. 


Do you feel fit and well enough to have a fibroblast procedure today?*
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 have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster etc?*
No
Yes

If so please list:
Are you currently taking any medications?*
No
Yes

If so please list:
Do you have any imminent holiday plans?*
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?*
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 Haemophilia?*
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 suffer from Keloid scarring?*
No
Yes

If you suffer from any of the above it is important that you notify your specialist who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. 


Notes to discuss:
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history it is my responsibility to inform my specialist.

FIBROBLAST TREATMENT PLAN 

This part of the consultation record is to be completed by the specialist in order to record important elements of the treatment. This form must be kept with the clients Medical and Consent forms.

PLEASE USE THIS FORM TO RECORD THE TREATMENT OF ONE AREA ONLY. All other treatments must be recorded on separatetreatment planforms. 


Treatment area(s) being completed:

Number of treatments recommended:
Treatment number: (only 4 treatments per 1 area)*
Indicate which scale:*

For first visit only: Following consultation with your client, what is the agreed treatment and how many visits will it take to achieve?

What is the predicted outcome and recommendations?

For 2nd and subsequent visits: CLIENT MUST COMPLETE A RECONSENT FORM. 


Were your clients expectations met?

Did the area heal as described?

What is the agreed objective for today's procedure?

What is the predicted outcome and recommendations?

Describe the treatment area including a description of the appearance of the skin:
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Occupation:

Treatment Area:

Price Agreed:

Package:
PATCH TEST/WAIVER*

MEDICAL FORM

Have you received any skin tightening treatment before?*
No
Yes

If Yes, please answer the following questions: 


How long ago was your treatment?
Where you happy with the result?
Yes
No

What procedure did you receive?

If no, please explain the reasons why.

At what clinic did you receive the treatment?
Are you over the age of 18?*
No
Yes
Are you pregnant?*
No
Yes
Are you under the influence of alcohol or drugs?*
No
Yes
Are you in good health?*
No
Yes

MEDICAL CONDITIONS

Please answer YES or NO to the following questions. These details will then be discussed (in confidence) with your specialist. 


Do you feel fit and well enough to have a fibroblast procedure today?*
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 have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster etc?*
No
Yes

If so please list:
Are you currently taking any medications?*
No
Yes

If so please list:
Do you have any imminent holiday plans?*
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?*
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 Haemophilia?*
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 suffer from Keloid scarring?*
No
Yes

If you suffer from any of the above it is important that you notify your specialist who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. 


Notes to discuss:
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history it is my responsibility to inform my specialist.

FIBROBLAST TREATMENT PLAN 

This part of the consultation record is to be completed by the specialist in order to record important elements of the treatment. This form must be kept with the clients Medical and Consent forms.

PLEASE USE THIS FORM TO RECORD THE TREATMENT OF ONE AREA ONLY. All other treatments must be recorded on separatetreatment planforms. 


Treatment area(s) being completed:

Number of treatments recommended:
Treatment number: (only 4 treatments per 1 area)*
Indicate which scale:*

For first visit only: Following consultation with your client, what is the agreed treatment and how many visits will it take to achieve?

What is the predicted outcome and recommendations?

For 2nd and subsequent visits: CLIENT MUST COMPLETE A RECONSENT FORM. 


Were your clients expectations met?

Did the area heal as described?

What is the agreed objective for today's procedure?

What is the predicted outcome and recommendations?

Describe the treatment area including a description of the appearance of the skin:
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Occupation:

Treatment Area:

Price Agreed:

Package:
PATCH TEST/WAIVER*

MEDICAL FORM

Have you received any skin tightening treatment before?*
No
Yes

If Yes, please answer the following questions: 


How long ago was your treatment?
Where you happy with the result?
Yes
No

What procedure did you receive?

If no, please explain the reasons why.

At what clinic did you receive the treatment?
Are you over the age of 18?*
No
Yes
Are you pregnant?*
No
Yes
Are you under the influence of alcohol or drugs?*
No
Yes
Are you in good health?*
No
Yes

MEDICAL CONDITIONS

Please answer YES or NO to the following questions. These details will then be discussed (in confidence) with your specialist. 


Do you feel fit and well enough to have a fibroblast procedure today?*
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 have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster etc?*
No
Yes

If so please list:
Are you currently taking any medications?*
No
Yes

If so please list:
Do you have any imminent holiday plans?*
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?*
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 Haemophilia?*
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 suffer from Keloid scarring?*
No
Yes

If you suffer from any of the above it is important that you notify your specialist who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. 


Notes to discuss:
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history it is my responsibility to inform my specialist.

FIBROBLAST TREATMENT PLAN 

This part of the consultation record is to be completed by the specialist in order to record important elements of the treatment. This form must be kept with the clients Medical and Consent forms.

PLEASE USE THIS FORM TO RECORD THE TREATMENT OF ONE AREA ONLY. All other treatments must be recorded on separatetreatment planforms. 


Treatment area(s) being completed:

Number of treatments recommended:
Treatment number: (only 4 treatments per 1 area)*
Indicate which scale:*

For first visit only: Following consultation with your client, what is the agreed treatment and how many visits will it take to achieve?

What is the predicted outcome and recommendations?

For 2nd and subsequent visits: CLIENT MUST COMPLETE A RECONSENT FORM. 


Were your clients expectations met?

Did the area heal as described?

What is the agreed objective for today's procedure?

What is the predicted outcome and recommendations?

Describe the treatment area including a description of the appearance of the skin:
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Occupation:

Treatment Area:

Price Agreed:

Package:
PATCH TEST/WAIVER*

MEDICAL FORM

Have you received any skin tightening treatment before?*
No
Yes

If Yes, please answer the following questions: 


How long ago was your treatment?
Where you happy with the result?
Yes
No

What procedure did you receive?

If no, please explain the reasons why.

At what clinic did you receive the treatment?
Are you over the age of 18?*
No
Yes
Are you pregnant?*
No
Yes
Are you under the influence of alcohol or drugs?*
No
Yes
Are you in good health?*
No
Yes

MEDICAL CONDITIONS

Please answer YES or NO to the following questions. These details will then be discussed (in confidence) with your specialist. 


Do you feel fit and well enough to have a fibroblast procedure today?*
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 have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster etc?*
No
Yes

If so please list:
Are you currently taking any medications?*
No
Yes

If so please list:
Do you have any imminent holiday plans?*
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?*
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 Haemophilia?*
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 suffer from Keloid scarring?*
No
Yes

If you suffer from any of the above it is important that you notify your specialist who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. 


Notes to discuss:
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history it is my responsibility to inform my specialist.

FIBROBLAST TREATMENT PLAN 

This part of the consultation record is to be completed by the specialist in order to record important elements of the treatment. This form must be kept with the clients Medical and Consent forms.

PLEASE USE THIS FORM TO RECORD THE TREATMENT OF ONE AREA ONLY. All other treatments must be recorded on separatetreatment planforms. 


Treatment area(s) being completed:

Number of treatments recommended:
Treatment number: (only 4 treatments per 1 area)*
Indicate which scale:*

For first visit only: Following consultation with your client, what is the agreed treatment and how many visits will it take to achieve?

What is the predicted outcome and recommendations?

For 2nd and subsequent visits: CLIENT MUST COMPLETE A RECONSENT FORM. 


Were your clients expectations met?

Did the area heal as described?

What is the agreed objective for today's procedure?

What is the predicted outcome and recommendations?

Describe the treatment area including a description of the appearance of the skin:
Participant's 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*
Check to receive information, news, and discounts by e-mail.
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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Occupation:

Treatment Area:

Price Agreed:

Package:
PATCH TEST/WAIVER*

MEDICAL FORM

Have you received any skin tightening treatment before?*
No
Yes

If Yes, please answer the following questions: 


How long ago was your treatment?
Where you happy with the result?
Yes
No

What procedure did you receive?

If no, please explain the reasons why.

At what clinic did you receive the treatment?
Are you over the age of 18?*
No
Yes
Are you pregnant?*
No
Yes
Are you under the influence of alcohol or drugs?*
No
Yes
Are you in good health?*
No
Yes

MEDICAL CONDITIONS

Please answer YES or NO to the following questions. These details will then be discussed (in confidence) with your specialist. 


Do you feel fit and well enough to have a fibroblast procedure today?*
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 have any allergies or have you experienced any allergic reactions to medicine or products such as latex gloves, plaster etc?*
No
Yes

If so please list:
Are you currently taking any medications?*
No
Yes

If so please list:
Do you have any imminent holiday plans?*
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?*
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 Haemophilia?*
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 suffer from Keloid scarring?*
No
Yes

If you suffer from any of the above it is important that you notify your specialist who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. 


Notes to discuss:
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history it is my responsibility to inform my specialist.

FIBROBLAST TREATMENT PLAN 

This part of the consultation record is to be completed by the specialist in order to record important elements of the treatment. This form must be kept with the clients Medical and Consent forms.

PLEASE USE THIS FORM TO RECORD THE TREATMENT OF ONE AREA ONLY. All other treatments must be recorded on separatetreatment planforms. 


Treatment area(s) being completed:

Number of treatments recommended:
Treatment number: (only 4 treatments per 1 area)*
Indicate which scale:*

For first visit only: Following consultation with your client, what is the agreed treatment and how many visits will it take to achieve?

What is the predicted outcome and recommendations?

For 2nd and subsequent visits: CLIENT MUST COMPLETE A RECONSENT FORM. 


Were your clients expectations met?

Did the area heal as described?

What is the agreed objective for today's procedure?

What is the predicted outcome and recommendations?

Describe the treatment area including a description of the appearance of the skin:
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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