Unit 4.4 – Client Consent Form Copy

Scheduled Treatment: Body/Face Fibroblast Plasma Treatment

Fibroblast Plasma treatment uses a plasma generating technology. The treatment stimulates the production of collagen and elastin. This effect enables your skin to rejuvenate its appearance by promoting the lifting, firming, tightening of the skin. The Fibroblast Plasma device is only to be used by a trained professional. You should be informed of the aftercare treatment plan at your test patch appointment. Proper aftercare is essential to optimizing your results from your treatment. Only a licensed dermatologist or a medical doctor shall remove skin lesions or moles in case of malignancy. The client agrees they must always consult with a doctor prior to treating spots, or birthmarks. The client confirms that they do not suffer from any of the following contraindications.

If you have any of the following contraindications, please tick from the boxes below.

Do you have any current or chronic medical illnessDo you suffer from herpes simplexAre you currently under a doctors careAre you taking any photosensitive medication or blood thinnersAre you pregnant or breastfeedingDo you have a history of keloid scarringDo you have metal implantsHave you have unprotected sun exposure in the area in the past 4 weeksAre you using prescription exfoliants or Vitamin A,B or C in the past 4 weeksDo you have or had any form of cancerDo you have diabetes or epilepsyDo you have a history of vitiligoDo you have a history of hyperpigmentationDo you have a pacemakerDo you have high blood pressure

Client statement:

I signed below, state and confirm with my signature, that during the consultation taking place on . I was fully informed about the treatment with . I understand the given information about the aforementioned treatment. I further confirm with my signature, that I have none of the contraindications stated above and I am aware that by giving information that is not true I expose myself to a possibility of health problems. Based on the given information that I consider full and sufficient for my decision and after careful consideration fully and with no reservations, I give my consent with the application of the treatment.

Signature