Plasma Fibroblast Consultation and Consent Form

Client Details

Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently, or possibly may be, pregnant? *

Do any of the following apply to you? Please tick all that apply.

Breastfeeding Allergic to topical anesthetic preparations Currently have an infection at the treatment site Using isotretinoin for wrinkles or acne Have a history of keloids Have a history of hypertrophic scarring

Do you have any other medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

What are your main skin concerns? *

What are your goals and expectations of the treatment? *

Fitzpatrick skin types:

1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

Which of the above skin types would you say is closest to your skin? *

Treatment Information

What is Plasma Fibroblast?

Plasma fibroblast therapy targets fibroblasts. These are collagen and protein-producing cells in the dermis, the layer of skin just below your outermost skin layer. Fibroblasts play an important role in helping skin wounds heal as well as maintaining skin firmness and tightness.

Plasma fibroblast therapy uses a pen-like device that discharges a high-frequency electric current to small areas of the skin. The plasma tip doesn’t directly touch the skin, but instead releases a targeted current just above the skin. The hot current creates small holes, or micro-injuries, in the skin’s layer.

Healthcare providers may also call this approach plasma skin resurfacing.

Plasma fibroblast therapy may be used to treat the following conditions:

Acne scars
Photo aging, including age spots
Seborrheic keratosis
Wrinkled skin, including the eyelids, neck, jawline, and above the lips

Possible Side Effects

The Plasma Fibroblast treatment will produce side effects after the procedure. This is common and normal.

Side effects expected include:

Redness
Swelling
Mild hypopigmentation (light spots)
Mild hyperpigmentation (dark spots)
Skin peeling and crusting

Eye Treatment Area

Day of treatment: Some swelling. Feels hot like a sunburn. This feeling can last for up to 3 hours +
Day 1 (Next day post-treatment): Lots of swelling (the most swelling), especially in the morning.
Day 2: Swelling.
Day 3: Itchy sensation and tightness. Swelling decreases. Dots dry and may start to fall off.

Swelling

You will notice most of the swelling on the first morning after treatment, particularly around the eyes. Swelling usually lasts two to three days. To minimise swelling try the following:

Follow Lymphatic Drainage Protocols
Sleep elevated the first night - Use as many pillows as you can tolerate
Avoid salt and alcohol
Body dry brushing
Jade rolling

Heat/Sunburn/Stinging

Feeling hot like a sunburn stinging sensation is normal immediately after the treatment and for the rest of that night.

Itchiness

You will start to feel itchy from the 3^rd day. Do not pick at the dots. The itchiness sensation means that the dots are starting to heal and are getting ready to dry and fall off.

Dry skin

Your skin may feel dry, peel or flake. You may notice a “sandpaper” texture a few days after treatment. This is the treated tissue working its way out of your body as new fresh skin is regenerated.

Redness

Most redness resolves during the first week after treatment, but a rosy “glow” can remain for several weeks. After the carbon crusts (dots) have fallen off, 5 to 7 days after the treatment, that’s when you can apply your normal coverage of makeup.

Bronzing, Crusting and Small Dark Dots

The treatment causes destruction to microscopic cylinders of skin which then exfoliates during the healing process. The treatment can make the skin look bronzed, or small areas appear crusted (do not try to scratch them off). Scratching off any carbon deposits (dots) may result in infection, scarring and hypo-pigmentation of the skin that may not be able to be reversed. Please refrain from scratching any areas that are healing.

Raw Skin

If you develop areas of raw skin post treatment, you do not need to apply band-aids, but keep the areas moist and do not pick at them. They will heal very rapidly on their own and without problems.

Weeping

Initially, after treatment and for a day or so afterward, there may be occasional weeping (yellow pus). This is simply plasma and is a natural healing response. This simply flakes off after a few days but in some cases can take over 1 week.

Aftercare

Please read carefully.

For 1 week after treatment

Wash the area gently with warm water, carefully pat dry.
Apply aftercare cream twice a day - Your practitioner can advise you on the best type of cream to use
No makeup
No swimming
Do not use Actives or Anti Ageing Creams (Retinols, Tretonin, Retin A)
No sauna
No exposing the area to sunlight

For 2 weeks after treatment

Moisturise the area twice a day, using products that are hydrating and repairing. Ingredients such at Hyaluronic Acid and Centella help heal the skin as well as hydrating it.
Gentle cleansing
Do not use AHA’s, Glycolics or Retinols
Do not use exfoliating products

At all time during the course of treatment

Sun exposure should be avoided. If not possible, wear a sunscreen with a minimum SPF 50
Moisturise the area twice a day, using products that are hydrating and repairing. Ingredients such at Hyaluronic Acid and Centella help heal the skin as well as hydrating it. You want to ensure that the skin is prevented from drying out and peeling.
No sunbeds or tanning/sunbathing

Skin Care Products

All of your skin care products should be non-irritating and non-clogging for the first week or so after the treatment. For best results, we advise to use products that contain healing and hydrating ingredients such as Hyaluronic Acid and Centella. Do not use abrasive scrubs, toners, or products that contain glycolyic acids or Retin A. Read the product labels if you are unsure. Resume your normal skin care regimen only when your skin has fully healed.

Sunscreen

You should first apply sunscreen 20 minutes before going outside, and again, immediately before. After that, reapply your sunscreen every 2 hours. If direct sun exposure is necessary, wear a hat and clothing that covers the treated area. Use this regimen during the healing period and always.

Moisturiser

Remember that peeling and/or flaking is normal during the healing process. Therefore, the product should be non-irritating and non-clogging, or else you could develop breakouts. During the healing period your normal moisturiser may be too occlusive. Your practitioner can advise you on the best type of moisturiser to use. Reapply whenever your skin feels dry.

Cosmetic Treatments

Do not have any of the following cosmetic treatments on the treated area until the skin is fully healed.

Skin Needling
Laser Hair Removal
Laser Carbon Peel
PRP
Botox/Fillers
BB Glow
Active Peels (AHA, Enzyme, etc)

Please seek advice from your practitioner before having any other cosmetic treatments whilst your skin is still healing.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive a Plasma Fibroblast Treatment

Client Signature: *

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