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TLC Plasma Consent Form
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Consent & Release Agreement for Fibroblast Plama Skin tightening Treatment
This form is designed to give information needed to make an informed choice of whether or not to undergo the Fibroblast technique. Although Fibroblast technique is effective in most cases, absolutely no guarantee can be made regarding the clients benefit from the procedure. The results of the fibroblast treatment are permanent and may be visible for years. However, the ageing process is continuous and your skin ages every day both before and after the procedure and this cannot be stopped. The results of this treatment are permanent but when it comes to mimic facial lines (worry lines) these may recur quickly because muscles are stronger than the skin and therefore the lines will recur. This process uses an electrical arch which touches the skin surface. The heat widens the pores and is transferred into the epidermis all the way to the papillary layer which contains fibroblast cells. From this, excess skin is reduced and the results are comparable to lift procedures or wrinkle reduction. Most, if not all, methods of skin resurfacing are based on creating a controlled skin damage, which activates its healing. This leads to the skin remodelling and improvement in various signs of aging. After the treatment small dry spots/scabs form. They need 5-7 days to fall off and during this time the client should keep the skin surface clean and protect it with cream which we will present later. (For additional information on after care follow the aftercare advice below).
Please kindly go through this declaration form
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I have personally been advised by the technician about the type and purpose of the treatment, including information about possible anesthetization. I was thoroughly infomed about the required aftercare, as well as the necessary sun protection before and after the treatment and advised of the possible complications before and after the treatment. My personal situation was sufficiently discussed, as well as the realistic treatment results. I have received, read and understood the information provided to me regarding the treatment process and aftercare. I was also able to ask all the questions I was interested in and I have understood information provided.
What to expect ? Any Side Effects ?
Inflammation / Swelling
Scarring ( Rare )
Minor change in skin pigmentation ( rare)
Crusts which occur after treatment (lasts for 5-7 days)
Minor swelling after around the eye treatments (lasts around 3-5 days depending on sensitivity).
After the crusts falls off , a pink / red skin will be seen , which is normal and will slowly recover to your original skin tone
What to expect ? Any Side Effects ? (copy)
Inflammation / Swelling
Scarring ( Rare )
Minor change in skin pigmentation (very rare)
Crusts which occur after treatment (lasts for 5-7 days)
Minor swelling after around the eye treatments (lasts around 3-5 days depending on sensitivity).
Have you had any of the following in the last 30 days? If Yes , you are not suitable for this treatment
Alpha Hydroxy Acid (AHA)
Glycolic Products
Roaccutane
Blood Thinning Medication
Have you any of the following skin conditions?
Prone to Keyloid Scarring
Open wounds
Severe Acne
Psoriasis
Vitiligo
Lupus
Are you pregnant or breast feeding?
Do you have any auto-immune disorders or immune-deficient?
Additional contraindications:
If you have darker skin (Fitzpatrick scale skin type 6)
Any allergies or sensitivities to any of the products used during treatment
PHOTOGRAPHIC CONSENT
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I consent to photographs being taken BEFORE, DURING and AFTER my procedure.
IMPORTANT - PLEASE ACKNOWLEDGE
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I acknowledge having been informed that this cosmetic procedure is intended to improve texture tone and the appearance of wrinkles on the skin by using a controlled form of damage in the form of electric arc increasing fibroblast cells and collagen levels.
IMPORTANT - PLEASE ACKNOWLEDGE
*
I acknowledge the practice of Fibroblast treatment is not an exact science and no specific guarantees can or have been made concerning the results and that more than one treatment may be required to meet expectations. The cost of these were disclosed prior to the first treatment.
IMPORTANT - PLEASE ACKNOWLEDGE
*
I acknowledge my obligation to follow the written/spoken post treatment instructions and if after care advice is not followed there is a small risk that the following can occur: • Poor/slow healing • Pigmentation • Recurrence of original condition I have been advised what can be done if this occurs with my technician.
IMPORTANT - PLEASE ACKNOWLEDGE
*
I certify that I have read the above and discussed in full the treatment, aftercare and expectation of results, That I fully understand it all and I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. I hereby consent to the procedure. This constitutes to full disclosure and supersedes any previous verbal or written disclosures.
IMPORTANT - PLEASE ACKNOWLEDGE
*
You are required to read through the consent form thoroughly and sign this consultation record, giving consent for the procedure. Additionally, you are required to disclose your full medical history(which will be confidential) to confirm if you are the right candidate for this treatment, if you are not right candidate for this treatment, the specialist will not perform the treatment.
IMPORTANT - PLEASE ACKNOWLEDGE
*
You are required to read through the consent form thoroughly and sign this consultation record, giving consent for the procedure. Additionally, you are required to disclose your full medical history(which will be confidential) to confirm if you are the right candidate for this treatment, if you are not right candidate for this treatment, the specialist will not perform the treatment.
PATCH TEST
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I understand that a patch test can determine whether I will experience a reaction to the products used by the specialist within 48 hours prior to treatment. However, I accept this will be inconclusive as to whether I will have an alergic reaction anytime in the future. I therefore waiver my option to an allergy test and wish to proceed with treatment
I have undergone or been offered an allergy test prior to my initial treatment. I therefore release the specialist from liability to any allergic reactions I may experience associated with either the application of pre-treatment cream or any other products used after the procedure, immediately or at a later date.
CONSENT
*
I understand that my specialist will be in direct contact with me in relation to the fibroblast treatment. This treatment involves the use of a disposable probe. All other equipment is sterilized before use, all surfaces involved in the process are protected and gloves will be worn always by the specialist during treatment. I hereby consent to receiving Fibroblast Skin-Tightening treatment. My specialist has explained the terms and conditions of the treatment and I have fully understood these. I hereby give my consent to the specialist who is fully trained to carry out the treatment of my choice as requested by me on this consent and treatment agreement
PLEASE READ CAREFULLY AND CLICK SUBMIT BUTTON BELOW ONLY WHEN YOU ARE HAPPY TO PROCEED. ENSURE ALL POINTS HAVE BEEN DISCUSSED WITH YOUR SPECIALIST. YOU ARE GIVING CONSENT TO STATE YOU UNDERSTAND AND ACCEPT THESE TERMS.
*
You have chosen a cosmetic procedure that is not medically necessary
Results vary for every individual and so does the healing period.
You may be required to return for additional treatments before your overall procedure is deemed complete. Additional treatments cannot be performed untill 8 weeks from date of initial treatment to allow time for the treated area to fully heal.
The skin type of every client is different, and the healing process lead to some discoloration of the skin
After each treatment some swelling or redness make occur. In some case there may be extreme swelling. Your specialist will help give you appropriate advice to help reduce the risk
Since the treatment includes small burns to the skin, you may experience the smell of small charring. This is normal.
You must adhere to the aftercare advice given to you following the treatment as this will be crucial for the best outcome. Aftercare is very important and will reduce the risk of post procedural infection upon leaving the clinic.
You must let the treated area heal properly and follow steps on the aftercare instructions given to you in writing.
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