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Fibroblast Plasma Treatment Waiver Form

Fibroblast 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, one time use tip.

Before going through with treatment, you will be required to read through the terms and conditions and complete all forms 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.

Your technician will explain the full procedure and go over expectations with you. You will be given information pertaining to potential treatment benefits, likely results, explain risks, the healing process and all after-care procedures. All after-care advice will be emailed to you after your treatment, in addition we will send you home with all necessary products to care for the skin (depending on the package you purchased), along with instructions on how to apply all products.

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.

You have chosen to undergo a cosmetic procedure that is not medically indicated as necessary. Fibroblast Plasma therapy is an art and not an exact science. Results cannot be guaranteed because everyone's healing abilities are different and skin elasticity varies from person to person. 

A topical anesthetic will be applied to the face and your technician will check in with you frequently to make sure you are comfortable. If you are not, you agree to let your technician know immediately so that we can adjust as necessary or add topical numbing agents to the area before carrying on any further.

During treatment you will smell some charring of the skin as this procedure administers small dot sized 'burns' to the surface of the epidermis. Do not be alarmed about the smell as it is completely normal. If smells bother you please bring that up to your technician in advance and/ or bring a scented sheet or candle or essential oil diffuser that will help you to feel comfortable.

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 anesthetics that were used as well as the probe/ tip that was used. Before and after photos will be taken and will be used for promotional purposes. 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.

Skin types, skin conditions and healing is different for everyone so you may experience different results than someone else. Depending on your healing you may experience discoloration of the skin in the treated area. Skin rejuvenation and/ or microdermabrasion may be recommended to you to help shed any residual discolored skin after the healing process is fully complete.

After each treatment, swelling or redness may occur. Do not pick at or touch the skin. We insist on dry healing the skin for 2- 3 days post treatment. If necessary to wash the face please only do so with clean hands and a gentle facial cleanser such as Cetaphil. Pat dry the treated area with a clean towel. At this stage of healing we are mostly concerned about infection so it is best to keep the area clean and away from debris, sun and pollutants. In some cases there may be extreme swelling. You may apply ice packs covered with a clean towel to the treated area. Benadryl can also help with excessive swelling or heat. We are essentially causing micro-injuries to your skin which sends messages to your immune system to heal. This can lead to feelings of exhaustion in some cases. If you are feeling tired, please schedule rest time, drink lots of water, eat well and get good sleep, elevating the areas of the skin that were treated.

Healing stages vary but generally are as follows: The carbon crusts will fall off on their own between 8- 10 days, sometimes sooner. Full healing and maximum results continue through week 12 following the procedure. During this time you must stay out of the sun and wear a broad spectrum SPF of at least 50 every day. Exposure to sun while the skin is healing can cause hyperpigmentation and scarring. A hat and other coverings are recommended when you plan on being outside in the sun.

Be aware that skin altering procedures such as plastic surgery, implants, injectables, etc may altar the results of your fibroblast plasma treatment, so please disclose this information prior to your appointment so we can adjust your treatment plan accordingly.

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

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 fibroblast 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.

Today's Date: May 19, 2024

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Medical History Questions
Do you feel healthy enough to receive fibroblast 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.?*
Are you allergic to penicillin?*
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

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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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