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Name

Phone number*

Your email*

Address*

How were you referred to our facility?

Current Medications (Please list)*

Have you taken Accutane within the last year? *

Yes

No

Allergies (please list)*

Please Read Carefully. Have you had or do you currently have any of the following? Indicate YES with an by selecting the box

Cancer

High or Low Blood Pressure

Cold Sores

Heart Condition

Contact Lenses

Hemophilia

Dermatitis / Eczema

Hepatitis

Diabetes

Insulin dependent

Latex Sensitivity / Allergy

HIV / Aids

Hypoglycemia

Keloid Scars

Epilepsy

Problems with Healing

Tattoo / Permanent makeup

Thyroid Disease

Iron deficient / Anemic

Chemical Peels

Laser Resurfacing

Pregnant / Nursing

Plasma Pen Treatment

Hyperpigmentation

Melasma

Pacemaker

Cosmetic Surgery

Electrical implant with slow release medication

Lash Extensions

* If you suffer from any of the above, it is important that you notify your technician so that they can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. Additional Notes?

1. PLEASE READ CAREFULLY AND INITIAL / SIGN WHERE INDICATED. Ensure all points below have been discussed with the technician. You are signing to state that you understand and accept these terms.I acknowledge that any information contributed by me is true, to the best of my knowledge and that the present condition of the area that has been treated or will be treated is stated on this record. I fully understand that Aubrey James, Pro Plasma Esthetic / Lashes Locks Lips provides beauty services; There is no medical treatment involved. Plasma Pen and/or Jet Plasma Treatment is an art – not an exact science – and cannot guarantee an exact shrinkage result due to skin elasticity and individual which includes client’s health, genetics, lifestyle factors and following proper after care. (Initial below) *

2. I understand that Jet Plasma requires sessions, minimum 3 suggested for best results and that I may be required to return for additional treatments before the overall procedure is deemed complete. The payment for any additional work, (if applicable), will be agreed prior to the treatment commencing. Depending upon area of treatment, additional treatments cannot be performed until 6–8 weeks after 8 sessions same area to allow sufficient healing time. (Initial below)*

3. I realize that with any beauty service there may be certain risks, which must be understood. I will be fully responsible for any and all results, which may arise from these beauty services. I do hereby agree to hold Aubrey James, Pro Plasma Esthetic / Lashes Locks & Lips, their affiliates and employees/students free from any and all claims or suits for damage, for injuries or complications resulting from any beauty services provided by Aubrey James, Pro Plasma Esthetic / Lashes Locks & Lips. I understand that any spot removals / skin revision work performed may result in loss or gain of natural skin pigment. (Initials below)*

4. The skin type of every client is different and although Jet is safe for all Fitzpatrick, it is important you follow our aftercare instructions. Additional sessions may be advised, after the healing process is complete. (Initial below) *

5. I understand that taking before and after photographs of the said procedures is a requirement of such procedure. I grant permission for the use of the photographs, or electronic media images as identified, in any prestation of all kinds. (Initial below) *

6. I have received pre and post procedure instructions and will strictly adhere to them. I understand that my failure to do so may jeopardize my chances for a successful outcome. (Initial below) *

7. 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 medical history it is my responsibility to inform the technician. (Initial below) *

8. I am aware that any skin altering procedures such as Laser treatments, plastic surgery, implants, injectables and weight gain or loss may alter the treatment’s look. (Initial below) *

I, the client, agree with all points listed and discussed, and wish to proceed as recorded with procedure with Aubrey James, Pro Plasma Esthetic / Lashes Locks & Lips. I participated fully in the decision for the selected area or areas intended for my Jet Plasma Pen Treatment. I certify I have read and initialed the above paragraphs. I have had it explained to my understanding therefore I consent to this procedure. I accept full responsibility for the decision to receive this treatment and do not hold Aubrey James, Pro Plasma Esthetic / Lashes, Locks & Lips Inc responsible for any adverse reaction. (CLIENTS FULL NAME): *

Date (MM/DD/YYYY)*

Consent form