Plasmajet.pdf 53.53 KB

Name:

Date of birth:

Address:

Phone number:

Email:


Please read this consent form thoroughly. 

Please answer all questions. 

If you have any uncertainty regarding questions, please discuss with your doctor. 


Consent for Treatment:

I, ____________________________ , hereby consent to undergo mesotherapy for cellulite or fat reduction treatment by ____________. I understand that PlasmaJet treatment uses plasma energy to improve skin texture, tone, and tightness. It is commonly used for treating fine lines, wrinkles, acne scars, pigmentation, and other skin imperfections.

Treatment Plan:

 - The procedure typically takes 30-60 minutes, depending on the treatment area.

- A topical numbing cream may be applied to minimize discomfort.

- The PlasmaJet device is used to deliver plasma energy to the skin, creating controlled micro-injuries.

- Post-treatment, soothing and hydrating products may be applied to the treated area.


Please answer the following questions.

Yes

No

1. Do you currently have an infection in the area you would like to treat?

Y

N

2. Do you have known allergies or sensitivity to ingredients intended to be used?

Y

N

3. Do you currently have open wound or cuts in the area you would like to treat?

Y

N

4. Do you have scalp conditions like psoriasis and eczema?

Y

N

5. Are you currently on blood thinners including aspirin?

Y

N

6. Are you currently pregnant or breastfeeding?

Y

N

7. Do you have a history of keloid scar formation?

Y

N

8. Do you have a history of poor wound healing?

Y

N

9. Do you have diabetes?

Y

N

10. Are you currently using steroid containing medication?

Y

N

11. Do you have high blood pressure or heart disease?

Y

N

 

Risks and side effects:



While PlasmaJet treatment is generally safe, potential risks and side effects include:

Y

N

               Redness, swelling, or discomfort in the treated area



               Scabbing or crusting of the treated skin

               Temporary skin sensitivity

               Hyperpigmentation or hypopigmentation



               Infection at the treatment site



               Allergic reactions to topical numbing agents or post-care products



              



Precautions and aftercare:

Y

N




- Inform your healthcare provider of any medical conditions, including skin conditions such as eczema, rosacea, or psoriasis.



- Discuss any medications you are taking, including prescription and over-the-counter medicines, vitamins, and herbal supplements.



- Avoid sun exposure and tanning beds for at least 24 hours before the procedure.



- Avoid using retinoids and other potent skincare products for several days before the procedure.




Y

N


Post-care instructions

Follow the post-care instructions provided by your healthcare provider.

- Avoid sun exposure and use a broad-spectrum sunscreen with at least SPF 30.

- Avoid strenuous exercise, saunas and steam rooms for 48 hours post-treatment.

- Avoid using makeup, retinoids and other potent skincare products for a specified period as advised by your healthcare provider.

 

Financial Responsibility: I understand that I am financially responsible for the Plasma jet treatment cost of sessions as discussed with the clinic.

Patient Consent: I have read and understand the above information about PlasmaJet treatment. I have discussed the procedure with my healthcare provider and have had all my questions answered to my satisfaction. I understand the risks and benefits associated with PlasmaJet treatment and agree to proceed with the treatment.


Signature of Patient: ________________________
Date: _______________

Signature of Healthcare Provider: ________________________
Date: _______________