Loading...

PlasmaLift Treatment Consent

  • I understand that Plasma is the 4th state of matter, which causes epidermal skin cells to sublimate upon contact. This stimulates the fibroblast cells in the dermis to produce and lay down new collagen causing a tightening affect which final results can be seen up to 12 weeks post treatment.
  • I have chosen a cosmetic procedure that is not medically necessary.
  • I understand that no person may receive PlasmaLift that appears to be under the influence of alcohol or drugs, and I am not under the influence of either.
  • I understand that the Plasma Lift procedure is an art process, not an exact science, and we cannot guarantee an exact result due to skin elasticity, the individual healing process, and the overall health of the individual.
  • I understand that I may be required to return for additional treatments before the overall procedure is deemed complete.
  • I understand that 12 weeks must pass between treatments to allow the skin to completely heal and go through the collagen production process. Although rare, it may take up to 6 months or longer to heal.
  • I understand that my specialist will keep a detailed record of my treatments as well as pre and post treatment photographs. This information will be stored securely and not shared with anyone without my permission.
  • I understand that everyone’s skin type and results are different. Although rare, it is possible that I may develop hyper or hypopigmentation. (Microdermabrasion or microneedling may be recommended before treatments begin or after the healing process is complete in order to enhance your results.)
  • I understand that some swelling and redness may occur after treatment and may be extreme in some cases. (Your specialist will give you appropriate advice to help reduce the risk.)
  • I understand that I may feel some discomfort during the treatment. (Your specialist will do everything they can to make you comfortable.)
  • I understand that I may smell ozone and/or a charring scent. (This is perfectly normal and is the result of the sublimation of skin cells. You may bring or request essential oils to relieve the smell.)
  • I understand that I must adhere to the preparation and aftercare Instructions as well as any advice given to me following treatment in order to reduce the risk of post procedural infection.
  • I understand that I must let the treated area heal properly, and I will void picking, plucking, scratching, or knocking the skin as this will hinder the healing process and results.
  • I understand that skin-altering procedures such as plastic surgery, implants, injectables, and weight gain may alter the Plasma Lift results.
  • I understand that although the results are permanent, my skin will continue to age, and I may need more treatments someday.
  • I understand that it is my responsibility to inform my technician of any questions or concerns I may have about this procedure.
  • I filled out the medical history form and was truthful in my responses.


Date: October 26, 2021

PLASMALIFT POST-PROCEDURE INFORMATION & INSTRUCTIONS

  • Anything that touches the treated area must be CLEAN! Fingers, ice packs, towels, gauze, pillow case, etc…
  • The mild sunburn feeling most people have following the procedure should resolve within 12-48 hours.  If your skin feels really uncomfortable, an anti-inflammatory (Advil) or an antihistamine (Benadryl) can be taken.
  • It is normal to have some swelling, especially in more delicate skin like the eyes. Swelling can last anywhere from 2-4 days depending on how you tend to heal, and ice may be used to reduce swelling. A frozen bag of peas works very well wrapped in a clean paper towel.
  • If you have any additional weeping where your skin was treated, gently pat the area with provided gauze and MicroTonic and apply MicroGel.
  • As your skin begins to heal, the dots will dry and crust over. Crusts will flake off 5-8 days later.
  • DO NOT PICK or scratch the crusting as it can lead to infection or scarring. It is important to keep this area clean.
  • Make sure to sleep on a CLEAN pillowcase and do your best to sleep on your back.
  • Refrain from working out for at least two days.
  • Boil some water to have on hand for cleaning the treated area(s). If you cannot boil water, use distilled water. Just know that distilled is not sterile.
  • Twice daily, morning and evening, carefully clean (splash or use a spray bottle) the areas with the water you have boiled and pat dry with a clean towel. Then, use a cotton square to carefully dab MicroTonic onto treated area(s). Once dry, apply MicroGel.
  • If you purchased concealer, dab it on very carefully with a soft makeup sponge after MicroGel has dried. DO NOT use any other makeup. This is specially designed for irritated skin after PlasmaLift Treatments. Wash it off gently with water only.
  • After the crusts fall off ON THEIR OWN, pink/red skin will be left behind. This can last 4-6 weeks. Now, you can use a gentle cleanser instead of the boiled water. If you still have MicroTonic and MicroGel, apply those and then add MicroBalm. Use all of the after care products until you run out.
  • Regular makeup can be applied AFTER crusts have completely fallen off.
  • Use SPF 30-50 sunscreen lotion daily once the crusts fall off for at least 3-4 months post treatment. Daily use is encouraged to prevent signs of aging.
  • Swimming and sauna activities are only permitted 2 weeks post treatment and once all the crusts have fallen off the skin.                                                    
  • DO NOT use alcohol-based cleansers, as this will slow down the healing process.
  • If at any time the treated area(s) become too hot, red, or shows sign of pus, please contact us for advice as you may be developing an infection.
  • You must wait 12 weeks for another treatment to allow for proper healing.

I have read and agree to follow all aftercare instructions.


Date: October 26, 2021

PLASMALIFT PRE-TREATMENT INSTRUCTIONS

  • It is recommended that sun protection of SPF 30-50 be used daily for at least 2 weeks prior to the Plasma Lift treatment(s).
  • It is also recommended to start taking the Beauty Blend supplement (or extra Vitamin C) two weeks before and after treatment to aid in the skin’s healing process.
  • Depending on your needs, microneedling and or red light therapy may be recommended to enhance your PlasmaLift results.
  • Skincare products with ingredients such as retinols, alpha-hydroxy acids (AHAs), tretinoin or any type of Vitamin A derivatives should be avoided two weeks prior to treatment as well as two weeks post-treatment.
  • Please come to your appointment with a clean face, free of makeup and moisturizers.
  • If you have a history of cold sores, please take your medication three days before and three days following PlasmaLift treatment or as directed by your doctor.
  • Photographs will be taken by the specialist “before and after” treatment as well as at a later date for comparison.
  • If you have a tendency to get cold, bring a blanket with you just in case.
  • It is recommended to not wear contact lenses if we are treating the eye area. Contacts may be put in after treatment, but glasses are recommended in case you have excessive swelling.
  • I absolutely love kids, but due to state laws, minors are not allowed in the salon.

As a client of Plaxel USA PlasmaLift, I understand that all treatment, medical history, consent, and waiver forms must be completed and signed to ensure that I understand the potential benefits and risks associated with the PlasmaLift procedure(s). I agree to follow the preparation instructions. I also understand that I will receive the best, safest, and most successful treatment possible.


Date: October 26, 2021

First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
First Client's Information

Spot Test Agreement/Waiver

Check one: *
I received a spot test and testify that I had no allergic reaction to the applied creams or plasma treatment. I also understand that this spot test can be inconclusive of long-term allergies, and I do not hold my technician liable for any such allergies that may occur immediately or sometime in the future.
I have decided to waive the spot test and do not hold my specialist responsible for any allergic reaction I may have to any creams or plasma treatment used during my treatment, immediately after, or sometime in the future.

Spot Test Date

Photographic Consent

Check one: *
CONSENT. I consent to photographs/video being taken BEFORE, DURING, and AFTER my procedure(s). I agree to these being used for promotional and/or educational purposes.
DECLINE. I consent to photographs/video being taken BEFORE, DURING and AFTER my procedure(s). I agree to these being stored with my case file and I do not consent that these images be used for promotional and/or educational purposes.

I hereby consent to receiving PlasmaLift treatment(s), and this consent is applicable to all future PlasmaLift treatments I may receive. My technician has explained the terms and conditions of the treatment, and I have been given sufficient answers to all of my questions. I have a complete understanding of this procedure. I hereby give written consent to


my PlasmaLift specialist,

to carry out the PlasmaLift treatment I have requested.

First Client's Signature*
Second Client's Name

First Name*

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

Spot Test Agreement/Waiver

Check one: *
I received a spot test and testify that I had no allergic reaction to the applied creams or plasma treatment. I also understand that this spot test can be inconclusive of long-term allergies, and I do not hold my technician liable for any such allergies that may occur immediately or sometime in the future.
I have decided to waive the spot test and do not hold my specialist responsible for any allergic reaction I may have to any creams or plasma treatment used during my treatment, immediately after, or sometime in the future.

Spot Test Date

Photographic Consent

Check one: *
CONSENT. I consent to photographs/video being taken BEFORE, DURING, and AFTER my procedure(s). I agree to these being used for promotional and/or educational purposes.
DECLINE. I consent to photographs/video being taken BEFORE, DURING and AFTER my procedure(s). I agree to these being stored with my case file and I do not consent that these images be used for promotional and/or educational purposes.

I hereby consent to receiving PlasmaLift treatment(s), and this consent is applicable to all future PlasmaLift treatments I may receive. My technician has explained the terms and conditions of the treatment, and I have been given sufficient answers to all of my questions. I have a complete understanding of this procedure. I hereby give written consent to


my PlasmaLift specialist,

to carry out the PlasmaLift treatment I have requested.

Third Client's Name

First Name*

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

Spot Test Agreement/Waiver

Check one: *
I received a spot test and testify that I had no allergic reaction to the applied creams or plasma treatment. I also understand that this spot test can be inconclusive of long-term allergies, and I do not hold my technician liable for any such allergies that may occur immediately or sometime in the future.
I have decided to waive the spot test and do not hold my specialist responsible for any allergic reaction I may have to any creams or plasma treatment used during my treatment, immediately after, or sometime in the future.

Spot Test Date

Photographic Consent

Check one: *
CONSENT. I consent to photographs/video being taken BEFORE, DURING, and AFTER my procedure(s). I agree to these being used for promotional and/or educational purposes.
DECLINE. I consent to photographs/video being taken BEFORE, DURING and AFTER my procedure(s). I agree to these being stored with my case file and I do not consent that these images be used for promotional and/or educational purposes.

I hereby consent to receiving PlasmaLift treatment(s), and this consent is applicable to all future PlasmaLift treatments I may receive. My technician has explained the terms and conditions of the treatment, and I have been given sufficient answers to all of my questions. I have a complete understanding of this procedure. I hereby give written consent to


my PlasmaLift specialist,

to carry out the PlasmaLift treatment I have requested.

Fourth Client's Name

First Name*

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

Spot Test Agreement/Waiver

Check one: *
I received a spot test and testify that I had no allergic reaction to the applied creams or plasma treatment. I also understand that this spot test can be inconclusive of long-term allergies, and I do not hold my technician liable for any such allergies that may occur immediately or sometime in the future.
I have decided to waive the spot test and do not hold my specialist responsible for any allergic reaction I may have to any creams or plasma treatment used during my treatment, immediately after, or sometime in the future.

Spot Test Date

Photographic Consent

Check one: *
CONSENT. I consent to photographs/video being taken BEFORE, DURING, and AFTER my procedure(s). I agree to these being used for promotional and/or educational purposes.
DECLINE. I consent to photographs/video being taken BEFORE, DURING and AFTER my procedure(s). I agree to these being stored with my case file and I do not consent that these images be used for promotional and/or educational purposes.

I hereby consent to receiving PlasmaLift treatment(s), and this consent is applicable to all future PlasmaLift treatments I may receive. My technician has explained the terms and conditions of the treatment, and I have been given sufficient answers to all of my questions. I have a complete understanding of this procedure. I hereby give written consent to


my PlasmaLift specialist,

to carry out the PlasmaLift treatment I have requested.

Fifth Client's Name

First Name*

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

Spot Test Agreement/Waiver

Check one: *
I received a spot test and testify that I had no allergic reaction to the applied creams or plasma treatment. I also understand that this spot test can be inconclusive of long-term allergies, and I do not hold my technician liable for any such allergies that may occur immediately or sometime in the future.
I have decided to waive the spot test and do not hold my specialist responsible for any allergic reaction I may have to any creams or plasma treatment used during my treatment, immediately after, or sometime in the future.

Spot Test Date

Photographic Consent

Check one: *
CONSENT. I consent to photographs/video being taken BEFORE, DURING, and AFTER my procedure(s). I agree to these being used for promotional and/or educational purposes.
DECLINE. I consent to photographs/video being taken BEFORE, DURING and AFTER my procedure(s). I agree to these being stored with my case file and I do not consent that these images be used for promotional and/or educational purposes.

I hereby consent to receiving PlasmaLift treatment(s), and this consent is applicable to all future PlasmaLift treatments I may receive. My technician has explained the terms and conditions of the treatment, and I have been given sufficient answers to all of my questions. I have a complete understanding of this procedure. I hereby give written consent to


my PlasmaLift specialist,

to carry out the PlasmaLift treatment I have requested.

Sixth Client's Name

First Name*

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

Spot Test Agreement/Waiver

Check one: *
I received a spot test and testify that I had no allergic reaction to the applied creams or plasma treatment. I also understand that this spot test can be inconclusive of long-term allergies, and I do not hold my technician liable for any such allergies that may occur immediately or sometime in the future.
I have decided to waive the spot test and do not hold my specialist responsible for any allergic reaction I may have to any creams or plasma treatment used during my treatment, immediately after, or sometime in the future.

Spot Test Date

Photographic Consent

Check one: *
CONSENT. I consent to photographs/video being taken BEFORE, DURING, and AFTER my procedure(s). I agree to these being used for promotional and/or educational purposes.
DECLINE. I consent to photographs/video being taken BEFORE, DURING and AFTER my procedure(s). I agree to these being stored with my case file and I do not consent that these images be used for promotional and/or educational purposes.

I hereby consent to receiving PlasmaLift treatment(s), and this consent is applicable to all future PlasmaLift treatments I may receive. My technician has explained the terms and conditions of the treatment, and I have been given sufficient answers to all of my questions. I have a complete understanding of this procedure. I hereby give written consent to


my PlasmaLift specialist,

to carry out the PlasmaLift treatment I have requested.

Seventh Client's Name

First Name*

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

Spot Test Agreement/Waiver

Check one: *
I received a spot test and testify that I had no allergic reaction to the applied creams or plasma treatment. I also understand that this spot test can be inconclusive of long-term allergies, and I do not hold my technician liable for any such allergies that may occur immediately or sometime in the future.
I have decided to waive the spot test and do not hold my specialist responsible for any allergic reaction I may have to any creams or plasma treatment used during my treatment, immediately after, or sometime in the future.

Spot Test Date

Photographic Consent

Check one: *
CONSENT. I consent to photographs/video being taken BEFORE, DURING, and AFTER my procedure(s). I agree to these being used for promotional and/or educational purposes.
DECLINE. I consent to photographs/video being taken BEFORE, DURING and AFTER my procedure(s). I agree to these being stored with my case file and I do not consent that these images be used for promotional and/or educational purposes.

I hereby consent to receiving PlasmaLift treatment(s), and this consent is applicable to all future PlasmaLift treatments I may receive. My technician has explained the terms and conditions of the treatment, and I have been given sufficient answers to all of my questions. I have a complete understanding of this procedure. I hereby give written consent to


my PlasmaLift specialist,

to carry out the PlasmaLift treatment I have requested.

Eighth Client's Name

First Name*

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

Spot Test Agreement/Waiver

Check one: *
I received a spot test and testify that I had no allergic reaction to the applied creams or plasma treatment. I also understand that this spot test can be inconclusive of long-term allergies, and I do not hold my technician liable for any such allergies that may occur immediately or sometime in the future.
I have decided to waive the spot test and do not hold my specialist responsible for any allergic reaction I may have to any creams or plasma treatment used during my treatment, immediately after, or sometime in the future.

Spot Test Date

Photographic Consent

Check one: *
CONSENT. I consent to photographs/video being taken BEFORE, DURING, and AFTER my procedure(s). I agree to these being used for promotional and/or educational purposes.
DECLINE. I consent to photographs/video being taken BEFORE, DURING and AFTER my procedure(s). I agree to these being stored with my case file and I do not consent that these images be used for promotional and/or educational purposes.

I hereby consent to receiving PlasmaLift treatment(s), and this consent is applicable to all future PlasmaLift treatments I may receive. My technician has explained the terms and conditions of the treatment, and I have been given sufficient answers to all of my questions. I have a complete understanding of this procedure. I hereby give written consent to


my PlasmaLift specialist,

to carry out the PlasmaLift treatment I have requested.

Ninth Client's Name

First Name*

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

Spot Test Agreement/Waiver

Check one: *
I received a spot test and testify that I had no allergic reaction to the applied creams or plasma treatment. I also understand that this spot test can be inconclusive of long-term allergies, and I do not hold my technician liable for any such allergies that may occur immediately or sometime in the future.
I have decided to waive the spot test and do not hold my specialist responsible for any allergic reaction I may have to any creams or plasma treatment used during my treatment, immediately after, or sometime in the future.

Spot Test Date

Photographic Consent

Check one: *
CONSENT. I consent to photographs/video being taken BEFORE, DURING, and AFTER my procedure(s). I agree to these being used for promotional and/or educational purposes.
DECLINE. I consent to photographs/video being taken BEFORE, DURING and AFTER my procedure(s). I agree to these being stored with my case file and I do not consent that these images be used for promotional and/or educational purposes.

I hereby consent to receiving PlasmaLift treatment(s), and this consent is applicable to all future PlasmaLift treatments I may receive. My technician has explained the terms and conditions of the treatment, and I have been given sufficient answers to all of my questions. I have a complete understanding of this procedure. I hereby give written consent to


my PlasmaLift specialist,

to carry out the PlasmaLift treatment I have requested.

Tenth Client's Name

First Name*

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

Spot Test Agreement/Waiver

Check one: *
I received a spot test and testify that I had no allergic reaction to the applied creams or plasma treatment. I also understand that this spot test can be inconclusive of long-term allergies, and I do not hold my technician liable for any such allergies that may occur immediately or sometime in the future.
I have decided to waive the spot test and do not hold my specialist responsible for any allergic reaction I may have to any creams or plasma treatment used during my treatment, immediately after, or sometime in the future.

Spot Test Date

Photographic Consent

Check one: *
CONSENT. I consent to photographs/video being taken BEFORE, DURING, and AFTER my procedure(s). I agree to these being used for promotional and/or educational purposes.
DECLINE. I consent to photographs/video being taken BEFORE, DURING and AFTER my procedure(s). I agree to these being stored with my case file and I do not consent that these images be used for promotional and/or educational purposes.

I hereby consent to receiving PlasmaLift treatment(s), and this consent is applicable to all future PlasmaLift treatments I may receive. My technician has explained the terms and conditions of the treatment, and I have been given sufficient answers to all of my questions. I have a complete understanding of this procedure. I hereby give written consent to


my PlasmaLift specialist,

to carry out the PlasmaLift treatment I have requested.

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.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Spot Test Agreement/Waiver

Check one: *
I received a spot test and testify that I had no allergic reaction to the applied creams or plasma treatment. I also understand that this spot test can be inconclusive of long-term allergies, and I do not hold my technician liable for any such allergies that may occur immediately or sometime in the future.
I have decided to waive the spot test and do not hold my specialist responsible for any allergic reaction I may have to any creams or plasma treatment used during my treatment, immediately after, or sometime in the future.

Spot Test Date

Photographic Consent

Check one: *
CONSENT. I consent to photographs/video being taken BEFORE, DURING, and AFTER my procedure(s). I agree to these being used for promotional and/or educational purposes.
DECLINE. I consent to photographs/video being taken BEFORE, DURING and AFTER my procedure(s). I agree to these being stored with my case file and I do not consent that these images be used for promotional and/or educational purposes.

I hereby consent to receiving PlasmaLift treatment(s), and this consent is applicable to all future PlasmaLift treatments I may receive. My technician has explained the terms and conditions of the treatment, and I have been given sufficient answers to all of my questions. I have a complete understanding of this procedure. I hereby give written consent to


my PlasmaLift specialist,

to carry out the PlasmaLift treatment I have requested.

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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!