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Jet Plasma Treatment Consent Form

Jet Plasma Pen Therapy or Treatment is a procedure that can only be performed by a specially trained and qualified technician using FDA approved equipment to shrink and tighten the skin using a sterile, disposable, circuit board. This circuit board introduces 13,000 volts of plasma energy into all layers of the skin where collagen remodeling, increased product absorption, ozone sterilization and melanin suppression occur.

You will be given information pertaining to potential treatment benefits, likely results, risks, the healing process and all after-care protocol's. All after-care advice will be provided for you after your first session and emailed to you after your treatment, in addition you will be given full access to your technician to answer any questions. With Jet Plasma however, aftercare is extremely easy and explained further below.

Before going through with treatment, you will be required to read through these terms and conditions and fill out this form completely to the best of your knowledge. You are required to complete and sign the consultation record, thus giving your consent for treatment. You will need to disclose your medical history to determine whether or not you are a good candidate for this treatment. After medical analysis and review of your intake and consultation information, the specialist may decide to refuse treatment.

What can Jet Plasma treat? Answer: Acne, hyper-pigmentation, aging and damaged skin, laxity, collagen remodeling and wrinkles. Due to the channels in the skin being open after Jet, combing LED therapy after Jet is extremely beneficial and is offered through Fibroplasma Blushing. If you are interested in adding LED to your appointment for an additional cost, please let us know so we can make necessary scheduling adjustments and prepare your billing.

Contraindications will be recorded in the consultation form and will be referenced for any future treatments.

It is imperative that you bring up any parts of this form that you have questions about or that you need clarified. It is ultimately your responsibility to ensure that you understand the procedure and the expected outcomes before treatment begins. Please read carefully and sign where indicated only when you are comfortable to proceed. When you sign this document you are accepting these terms.

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You have chosen to undergo a cosmetic procedure that is not medically indicated as necessary. Jet Plasma therapy is able to prevent cell necrosis (cell death) by releasing plasma energy into the skin where cell membranes become excited and porous and allow active ingredients to be absorbed deep into the skin. Jet plasma can aid in resolving pigmentation by suppressing melanin production. Jet plasma has sterilization effects. It destroys acne causing bacteria on the skin and has an anti-inflammatory effect that reduces sebum production by 25%. Additionally, Jet plasma supports skin regeneration and tightening by increasing collagen production. Studies have shown a 14.8% increase in skin density after a single treatment. IMPORTANT: Results cannot be guaranteed because everyone's healing abilities are different, underlying health conditions can be present and variable environmental factors can have effect. 

You should arrive to your appointment with a clean face. We will make sure the skin is clean before administering Jet by cleansing you with Green Soap. Do not rely on us to clean your face for you, you must come with clean skin and we will do a final cleansing to ensure the plasma is not blocked by oil and sebum. During treatment you will not feel any pain or discomfort. You may experience some warmth in the skin, the sound of the machine expelling plasma and the smell of ozone that gets created during the process. If smells bother you please let us know in advance and/ or bring a scented sheet or candle or essential oil diffuser that will help you to feel comfortable.

In the very rare case that you experience any pain or discomfort during your short treatment, you agree to let your technician know as soon as possible so that we can adjust as necessary. 

Your technician will keep your personal and private information and photos secured. All records of your service area will be kept on file. We will keep a record of the products that were used and we will also store your circuit board Jet tip in a sterilized pouch for your next session. After 40 minutes have been clocked on a single circuit board tip, we will use a new circuit board Jet tip to continue your sessions until you have received all sessions. 'Before and after' photos will be taken and will be used as a valuable tool for clients to see the changes in the quality of their skin over time. These photos are also used for promotional purposes unless indicated otherwise. If you do not want your pictures to be used for this purpose, please clearly communication that to your technician prior to the day of your appointment.

After each treatment, professional grade serums and skincare products will be used to address the issues you want to address. Our aftercare products can sometimes change but they will always be applied after your Jet session to restore moisture and deliver active ingredients. During your appointment we  will discuss which product we should use on your skin, depending on your skin type, skin condition, presence of acne and desired results. You are also welcome to bring in your own skincare product for application after Jet. Product absorption is increased after Jet and the channels in the skin are open so efficacy of products is much higher after Jet plasma sessions, It is important not to apply anything to the skin other than what is applied in your session for 12 hours after your appointment. No makeup until after 12 hours. No exercise, sauna, steam or hot showers for 12 hours after treatment. No skincare other than what is applied in the clinic can be used for 12 hours. Do not even use SPF for the first 12 hours after treatment as this can cause buildup in the skin and have adverse effects.

Be advised that skin altering procedures such as: plastic surgery, implants, injectables, etc. may altar the results of your Jet plasma treatment, so please disclose this information prior to your appointment so we can adjust your treatment plan accordingly. Jet plasma is not recommended for: pregnant women, anyone with a pacemaker, someone who is hypersensitive, anyone with cancerous lesions, has implanted neurostimulators or any kind of implanted slow medication release device. Skin types, skin conditions and healing is different for everyone so you may experience different results than someone else receiving the same treatment. Be advised that your results are dependent on your health, lifestyle factors (drinking alcohol, smoking, food habits, etc), age and genetics, which are all factors out of our control.

Results are never 100% guaranteed and we cannot control how your body responds to this treatment. Fibroplasma Blushing's technicians are 100% exempt from any liability associated with your personal results from Jet plasma treatment. You agree and acknowledge that this is a cosmetic procedure that you have chosen at your own risk. Any concerns or dissatisfaction with your procedure and its results should be addressed to your tech artist personally and not taken to any public forum or social media platform. Slander and libel are serious offenses and legal action will be taken if any violations of these terms exists. Fibroplasma Blushing will not be held legally, financially or otherwise responsible for any outcome whatsoever as you have been informed extensively of the procedure, its risks, and potential results prior to your treatment.

By signing and initialing this waiver of liability, you are legally agreeing and adhering to the following terms & conditions:

Today's Date: April 15, 2025

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Address Line 1

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First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Second Client's Address Line 1

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Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Third Client's Address Line 1

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Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Address Line 1

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Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Address Line 1

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Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Address Line 1

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Seventh Client's Name

First Name*

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Last Name*
Seventh Client's Date of Birth*
Seventh Client's Address Line 1

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Eighth Client's Name

First Name*

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Last Name*
Eighth Client's Date of Birth*
Eighth Client's Address Line 1

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Ninth Client's Name

First Name*

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Ninth Client's Date of Birth*
Ninth Client's Address Line 1

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Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Address Line 1

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State

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Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Medical History Questions
Do you feel healthy enough to receive Jet plasma treatment?*
Do you have any allergies or have you experienced any allergic reactions to medicine or products such as latex or plaster?*
Do you smoke? (Cigarettes, cloves, cigars, vape pen, etc.?) Please note that smoking is a contraindication for this treatment and smokers should DISCONTIUE smoking before, during and after treatment for at least a week while still healing with the dots and even the full 12 weeks while collagen builds. Smoking can and will interfere with your healing.*
Are you currently taking any medication?*
Do you have or are you planning to have any injectables, fillers or chemical peels within the month prior to your treatment? please note: you must refrain from getting any of these things done 2- 4 weeks prior to your treatment.*
Do you suffer from epilepsy? (A disorder in which nerve cell activity in the brain is disturbed, causing seizures.)*
Are you knowingly suffering from any infectious diseases?*
Do you have high or low blood pressure?*
Do you have diabetes? (A group of diseases that result in too much sugar in the blood (high blood glucose).*
Do you have any respiratory problems?*
Do you get dizzy or have you ever fainted?*
Do you have HIV/ AIDS?*
Do you have any heart conditions?*
Do you have Hepatitis? (inflammation of the liver)*
Do you have any lymphatic or lymphatic drainage problems?*
Do you suffer from hemophilia? A disorder in which blood doesn't clot normally.*
Do you have any skin conditions or infections such as eczema, psoriasis, impetigo, etc.?*
Do you agree to proceed with this treatment at your own risk and release Lindsay at Fibroplasma Blushing of any financial or medical liability whatsoever; and agree to not slander Fibroplasma Blushing or anyone associated with this service? 'No' means we cannot move forward with your treatment. 'Yes' indicates we can move forward with your treatment. Please answer carefully.*

Any additional notes, comments or concerns that you would like 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*
Parent or Guardian's Address Line 1

Address Line 1

Address Line 2

City

State

Zip Code
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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