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Plasma Fibroblast/
Microneedling Consent Form

Madison Laser Spa
Plasma Fibroblast/
Microneedling Consent Form

No client may be treated without completing a consent form

    Fibroblast Plasma Treatment is a procedure performed by a specifically trained and qualified Technician. The equipment device will shrink the skin using a sterile disposable probe. Before treatment, you are required to complete and sign this consultation record, giving your absolute consent to treatment. It is a mandatory requirement to disclose your full medical history, which will determine whether you are an approved candidate for the proposed treatment. If the Technician-Spa does not feel you are suitable for the treatment, it will be at our discretion not to carry out the treatment.

    Your Technician will discuss the procedure to explain the process, benefits, and all risks. The Tech will review the healing process and advise further treatment if necessary. Contra-indications will be recorded on this consultation form and in your account profile which will be used as a reference for future visits.

    Aftercare information will be provided and your responsibility to follow for a successful healing process.

    The results of the fibroblast treatment are permanent and may be visible for years. However, the aging process is continuous and your skin ages every day, therefore the procedure does not stop your on going aging or skin condition that may later develop. 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 could recur.

    It is important you clearly mark any areas of this form you wish to have clarified or discuss further. It is ultimately YOUR responsibility to ensure you understand in full the procedure and the expected outcomes before treatment commences.

    Ensure all points below have been discussed with your Technician. You are signing to state that you understand and accept these terms. Terms of your treatment: You have chosen a cosmetic procedure that is not medically necessary.

    Fibroblast Plasma lift is an art process, not an exact science and cannot guarantee an exact shrinkage result due to skin elasticity and individual healing process. This consent package is designed to give information needed to make an informed choice of whether or not to undergo the Fibroblast treatment. Although Fibroblast technique is effective in most cases, absolutely no guarantee will be made regarding your (the clients) benefit or exact results from the procedure and NO refunds will be issued.

    This process uses an electrical arch that 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 remodeling 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.

    Your Technician will document a treatment plan to record your treatment and record before and after photos.

    The skin type of every client is different and the healing process may lead to some discoloration of the skin.

    After each treatment some swelling or redness may occur. In some cases there may be extreme swelling. Your Technician will give you appropriate advice to help reduce this risk. Throughout the treatment most clients experience some discomfort and pain, which is normal. Since the treatment includes small burns to the skin, you may experience the smell of charring, this is perfectly normal.

    Following aftercare instruction is very important and will reduce the risk of post procedural infection. You must let the treated area heal properly. Avoid picking, plucking, knocking as this will hinder the healing process and could make the treatment appears uneven thus requiring further work.

    I have personally been advised by the technician about the type and purpose of the treatment, including information about possible anesthetization. I was thoroughly informed 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 was also able to ask all the questions I was interested in and I have understood information provided. 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. 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 costs of these were disclosed prior to the first treatment. 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 and I have been advised what can be done if this occurs with my technician. 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. PATCH TEST
    (A) I understand that a sin 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 allergic reaction anytime in the future. I therefore waiver my option to an allergy test and wish to proceed with treatment.

    (B) I have undergone or been offered an allergy test prior to my initial treatment. I therefore release the Tech + Spa 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


    PHOTOGRAPHIC CONSENT: required for treatment.

    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)

    Glycolic Products


    Gold Therapy

    Blood Thinning Medication

    Have you any of the following skin conditions?

    Prone to Keloid Scarring

    Open wounds

    Severe Acne




    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?
    Please list

    Do you knowingly suffer from any infectious diseases; have any current virus or sickness?

    Have high or low blood pressure

    Have diabetes

    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.

    Contact Us (646) 370-3308