Loading...

I acknowledge that any information contributed by me is true, to the best of my knowledge and that the present condition of the area that has been treated or will be treated is stated on this record. I fully understand that Aubrey James, Pro Plasma Esthetic / Lashes Locks Lips provides beauty services; There is no medical treatment involved. Plasma Pen and/or Jet Plasma Treatment is an art - not an exact science - and cannot guarantee an exact shrinkage result due to skin elasticity and individual which includes client”s health, genetics, lifestyle factors and following proper after care.



I understand that Jet Plasma requires sessions, minimum 3 suggested for best results and that I may be required to return for additional treatments before the 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 6-8 weeks after 8 sessions same area to allow sufficient healing time



I realize that with any beauty service there may be certain risks, which must be understood. I will be fully responsible for any and all results, which may arise from these beauty services. I do hereby agree to hold Aubrey James, Pro Plasma Esthetic / Lashes Locks & Lips, their affiliates and employees/students free from any and all claims or suits for damage, for injuries or complications resulting from any beauty services provided by Aubrey James, Pro Plasma Esthetic / Lashes Locks & Lips. I understand that any spot removals / skin revision work performed may result in loss or gain of natural skin pigment.



The skin type of every client is different and although Jet is safe for all Fitzpatrick, it is important you follow our aftercare instructions. Additional sessions may be advised, after the healing process is complete



I understand that taking before and after photographs of the said procedures is a requirement of such procedure. I grant permission for the use of the photographs, or electronic media images as identified, in any presentation of all kinds



I have received pre and post procedure instructions and will strictly adhere to them. I understand that my failure to do so may jeopardize my chances for a successful outcome. 



 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 medical history it is my responsibility to inform the technician



I am aware that any skin altering procedures such as Laser treatments, plastic surgery, implants, injectables and weight gain or loss may alter the treatments look.



I, the client, agree with all points listed and discussed, and wish to proceed as recorded with procedure with Aubrey James, Pro Plasma Esthetic / Lashes Locks & Lips. I participated fully in the decision for the selected area or areas intended for my Jet Plasma Pen Treatment. I certify I have read and initialed the above paragraphs. I have had it explained to my understanding therefore I consent to this procedure. I accept full responsibility for the decision to receive this treatment and do not hold Aubrey James, Pro Plasma Esthetic/ Lashes, Locks & Lips inc responsible for any adverse reaction.


I agree to follow the aftercare I have been provided by my Jet Plasma practitioner. I understand if I do not follow the Aftercare instructions I have been given I may experience a negative outcome. Minimum 3 sessions are required for Jet Plasma


First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Click to customize section title
Do any of the following apply to you? *
Actively Received Chemotherapy or Radiation in Last 6 Months
Actively Receiving Chemotherapy or Radiation
Any Electrical Implanted Device
Botox Filler in Last 2 Weeks
Cancer
Cancerous Lesions on Treatment Area
Chemical Peels
Cold Sores
Contact Lenses
Cosmetic Surgery
Dermatitis/Eczema
Diabetes
Epilepsy
HIV / Aids
Heart Condition
Hemophilia
Hepatitis
High or Low Blood Pressure
Hyperpigmentation
Hypersensitive
Hypoglycemia
Implanted Neurostimulator
Implanted Slow Medication Release
Insulin Dependent
Iron Deficient/Anemia
Keloid Scars
Laser Resurfacing
Latex Allergy
Melasma
None of The Above
Pacemaker
Permanent Makeup/Tattoo on Area
Pregnant or Breastfeeding
Thyroid Disease
I understand this may require multiple sessions to see improvements. *
No
Yes
I answered everything to my best ability and honestly.*
No
Yes
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 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!