I consent to photographs being taken BEFORE, DURING, and AFTER my procedure. I agree to these being stored with my case file and will be used with the below written consent for promotional and social media purposes.
Male or Female
Have you received any skin tightening treatment before?
If Yes How long ago was your treatment?
What procedure did you receive?
At what clinic – spa did you receive the treatment?
Were you happy with the result?
If no, please explain the reasons why.
Are you over the age of 18?
Are you under the influence of alcohol or drugs?
Have you had any of the following in the last 30 days:
Alpha Hydroxy Acid (AHA)
Blood Thinning Medication
Have you any of the following skin conditions?
Prone to Keloid Scarring
Pregnant or breast feeding
Allergies or prior allergic reactions to medicine or products such as latex gloves, plaster
Autoimmune disorders or immune-deficient
Do you suffer from epilepsy
Are you currently taking any medication
MUST list all
Do you have or are you planning to have any injectable, fillers or chemical peels in the near future?
Do you knowingly suffer from any infectious diseases; have any current virus or sickness?
Have high or low blood pressure
Any respiratory or heart problems
Do you smoke
Prior Issues with scars – scar healing - keloid scarring
Suffer from dizziness or fainting attacks
Have Anxiety, depression, sleeping issues
Have HIV/AIDS (had HIV/AID that is now undetected)
Have Genital warts/ herpes / cold sores
Have Hepatitis, HPV, and active STD
Have Lymphatic problems
Suffer from Haemophilia
Have an allergy to penicillin
Prior or known REACTION to Lidocaine
Do you feel fit and well enough to have a Plasma pen lifting procedure today with consent that your medical history has been fully disclosed such that any information you have not communicated to Madison Laser Spa, that could produce adverse harmful reactions, confirm Madison Laser Spa or any staff treating you shall not be held at the accountability? If you suffer from any of the above it is important that you notify Madison Laser Spa who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health.
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history it is my responsibility to inform my specialist.
Contraindications: YOU CANNOT BE TREATED
Darker Skin Tones can not be treated ~ Fitzpatrick scale skin type 5 and 6
I agree with all points listed and discussed, and wish to proceed as recorded. I participated fully in the decision for selected area or areas intended for my treatment. I hereby agree to follow after advice.
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.