Consent Form

Name

Phone

Are you on any blood thinners?

Yes No

Are you pregnant?

Yes No

Do you have any skin disorder that will delay healing?

Yes No

Are you a Fitzpatrtick tone of a 4 or 5 or a hispanic, Asian, Indian, or African American decent?

Yes No

Are you prone to hyperpigmentation ? If so please book a consult.

Yes No

Are you a male?

Yes No

Are you a female?

Yes No

Are you prone to keloid scarring?

Yes No

Do you have abnormally thin skin?

Yes No

Are you taking any retinol, acutane, or have done Botox in the last 4 weeks?

Yes No

Are you prone to cold sores or herpes? If so please take your viral medication 1 week prior.

Yes No

Are you on blood thinners or a heavy smoker?

Yes No

Are you in good health?

Yes No

Do you have sensitive eyes or any eye condition that would cause the retina to detach?

Yes No

Are you an avid smoker? If yes please note your healing will be delayed.

Yes No

Do you understand if drinking coffee or on antibiotics the day of you will be more sensitive. We request you are not on either the day of.

Yes No

Are you voiding a patch test?

Yes No

Will you have any eminent holiday plans coming up? Will you be able to stay out of the sun at least a week while healing a cover up and wear sunscreen for that first 6 weeks?

Yes No

Do you understand we are not liable if you are not adhering to our guidlines for aftercare or don't follow up on your healing process. We request you make a follow up at least 2-4 weeks after the procedure.

Yes No

Thermal treatments like fibroblast lift is not suited for those with compromised barriers or thin skin. It's also not applicable for those with darker undertones. Do you have any of these?

Yes No

Have you had this treatment prior?

Yes No

Have you received this treatment from our company?

Yes No

Do you have a pacemaker?

Yes No

How old are you?

Please upload a picture or video of the areas that concern you and note what service you’d like to have done.

Do you agree to photo or video consent? Photos will still be taken and kept for practice use only in your medical files.

Yes No

Do you understand that deposits are non-refundable and secure your appointment time only?

Do you acknowledge that fibroblast treatments are considered an art, not an exact science, and individual results vary?

Yes No

Do you agree that touch-up sessions may be needed and are not included in the initial treatment price unless otherwise stated?

Yes No

Do you agree that no refunds will be issued once treatment has been rendered?

Yes No

Do you understand that healing is your body’s responsibility, and outcomes will depend on aftercare compliance and your skin’s natural response?

Yes No

Have you been informed that collagen remodeling may take up to 12 weeks and results are gradual?

Yes No

Do you understand that fibroblast treatments are elective and you are choosing to undergo this procedure at your own risk?

Yes No

Do you agree that your provider has explained possible side effects (redness, swelling, scabbing, hyperpigmentation, etc.) and you accept these risks?

Yes No

Do you confirm that you have provided accurate health information and will update your provider of any changes?

Yes No

Do you accept that your deposit will be forfeited if you reschedule or cancel without the required notice period?

Yes No

Fibroblast Plasma Lift Treatment Intake and Consent