Sample Consent Form 2018

Areton Ltd presents this document as a template for the convenience of its customers only and not any other party. It is strongly recommended you consult your insurer and your legal consultants before using this document (amendments may be required). Areton Limited does not assume any responsibility for any inclusions, mistakes or omissions within this document. It is advised to keep a signed copy for your record and one should be handed out to the client.
Download the Word Document
 

PLASMA FIBROBLAST THERAPY CONSENT

 

Client Name: ………………………………………………………………………………………………………

Email Address………………………………………………………………………………………………………

Mobile Number……………………………………………………………………………………………………

Date: …………… Emergency contact name………………………………

#………………………………………………………………………………………..

 

I confirm that I am over 18 and under 75 and that I have been advised of the following:

• The BeautyTeck has not been tested on children, breast-feeding or pregnant women and is therefore not recommended in these cases.

• Treatments with the BeautyTeck should be avoided if you have any serious underlying medical condition that prevents you from healing properly.

• The BeautyTeck is not recommended to be used on those clients with increased susceptibility to Keloid formation and hyper-trophic scarring.

• If you have ever had episodes of herpes simplex, it is recommended that you undergo a full course of antiviral treatments before you undergo any kind of treatment with the BeautyTeck plasma arc. Consult your health care practitioner for the correct medications.

• Treatments with this device are not recommended if you have a pace maker, diabetic pump or a metal implant.

• Effects of the BeautyTeck for simultaneous use with peeling, Botox, laser or ultrasound based treatments is unknown and should be avoided for at least two months after the last treatment.
a) in clients with a previous history of autoimmune diseases or receiving immunotherapy
b) into an area which has already been treated with a filling product (especially permanent filling materials such as Silicone or Aquamid) unless it is certain that the filling product is no longer present.
c) areas treated with lasers or cosmetic lasers.

A patch test is a necessary part of any BeautyTeck treatment. This lets us see how YOUR body is going to react to the treatment and how long it takes YOUR skin to heal and regenerate. In case you choose not to perform a patch test no responsibility is borne on any adverse reactions (very unlikely).

It is imperative that AFTERCARE instructions are followed as prescribed to minimize the likelihood of Adverse Reactions.

There is small risk of scarring, hypo-pigmentation or hyper-pigmentation which can be minimized, but can never be completely avoided. However these risks are greatly increased if the aftercare instructions are not strictly adhered to. Poor aftercare can cause serious detrimental results.

In case of tattoo or permanent make-up removal treatments, no known current treatment can guarantee a seamless disappearance of the tattoo. Tattoos of any kind may never completely disappear. Greatly fading the pigmentation is the main goal of this treatment. Although the likelihood of scarring, hyper-pigmentation, or hypo-pigmentation are very low, this always exists despite the method used to perform the treatment. It can be minimized but never completely ruled out.

The tattoo removal and permanent makeup treatment involves scabbing and the formation of new skin during the healing process. Therefore, the area will have a different skin texture after the scabs have fallen off. This is normal and to be expected. The area will usually blend in with the surrounding area over the course of the following months. In any case, please bear in mind that seamless results cannot be guaranteed after tattoo removal. Infections or early sun exposure during the healing period increases the likelihood of the potential adverse reactions listed above including scarring.

The number of sessions required to achieve the desired result will be determined by the type of treatment you request and the size of the area being treated. The minimum interval between treatments on the same area is 8 weeks. This minimum time period may be extended at discretion of your beauty practitioner, depending on your skin type and your individual reaction to the treatment.

The likelihood of hyper pigmentation is very low and can be minimized but never completely avoided. Hypo-pigmentation is a normal reaction in skin renewal and normally disappears after a few months. These risks are minimized by following the after-care recommendations and avoiding sun exposure and applying total sun block for the prescribed period. In certain circumstances red or pink spots where the treatment was carried out can develop and be visible for a few months. This is likely due to the use of cosmetic products after the treatment. These spots will eventually subside over time. It is recommended that you not use ANY product that hasn’t been given to you by your practitioner on the treated area until the scabs have fallen off.

Plasma Eyelid Tightening treatments with the “BeautyTeck” can result in some immediate reactions including redness, major swelling and discomfort or tenderness. Discomfort usually lasts up-to 24 hours after the treatment, sometimes slightly longer. Swelling can last up to five days. If any of these symptoms persist for more than six days, or if any other side effects develop, report them to your beauty practitioner and consult your doctor. Long term redness and slight tenderness may continue for a few weeks to a few months following the treatment.

Skin tightening procedures of any face or body area will probably scab up within 2-3 days. They may last for 10 days or more. Treated areas may be a different color and texture than the surrounding skin until the total healing process is finished. The area may be tender for a day or two but should not be painful. Full correction will not be achieved in one session. De-hydrated skin tissue will have a tighter appearance immediately after the procedure. As the skin heals and rehydrates, the area will appear slacker than the immediate results, but will tighten as collagen grows. Subsequent treatments will advance the tightening effects. It is impossible to get surgery type of tightness without having surgery. Please have realistic goals.

Reduced appearance of stretch marks and scars will be achieved, but until we see how your body reacts, we will not be able to give you the exact amount of necessary treatments to get the optimum effects.

As far as I know, I am not allergic to, or ever had any adverse reactions to topical lidocaine, benzocaine, tetracaine, salt, Dettol antiseptic solution, surgical or medical tape. Please initial __________

Please name any allergies that you have, including foods and medications:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

IF YOU EVER HAD EPISODES OF HERPES SIMPLEX IT IS RECOMMENDED TO UNDERGO A COMPLETE ANTIVIRAL COURSE TREATMENT BEFORE UNDERGOING ANY TREATMENT WITH THE DEVICE.


The aesthetic practitioner had:

• Provided me with sufficient information about the treatment in order to make an informed decision and I understand the risks involved. I understand that if I do not want to take those risks I can simply abstain from any treatment with the device.I have been given the opportunity to ask all of the questions I have about the treatments. The aesthetic practitioner has answered them to the best of his/her ability and I understand the answers.

• Also the aesthetic practitioner has provided sufficient time to consider whether I want to undergo the aesthetic treatment.

• Also the aesthetic practitioner has received relevant medical history information from me which I have answered to the best of my knowledge.

I understand the above directions and have been told what to expect and what to avoid. I acknowledge that it is my responsibility to promote common sense and cleanliness to prevent infection or scarring. I hereby agree that I will not hold the aesthetic practitioner/aesthetic clinic responsible for any actions that happen after I leave the establishment.

• I understand that I may call practitioner to ask questions about the procedure and after care that I just had.

• I understand that in order to minimize the risks of adverse reactions I have to provide pictures daily until the scabs have fallen off.

• I understand that in order to minimize the risks of adverse reactions, especially hyper-pigmentation I bust use physical suncreen PF50+ . I have to provide pictures weekly after the scabs have fallen off until three months after the treatment.

The practitioner’s Whatsapp contact………………………
The practitioner’s Email contact…………………………
The practitioner’s Phone number………………………….

I have read the above and consent to receiving the treatment at my own discretion.

Client’s signature: ………………………………….. Date: ………………………

I have decided not to perform a patch test.

Client’s signature: ………………………………….. Date: ………………………

PHOTOGRAPHS
I authorize the taking of photographs and video footage which will be retained as a private record for the clinic and practitioner.

Client’s signature: ………………………………….. Date: ………………………

I ALSO CONSENT THE USE OF MY PHOTOGRAPHS AND VIDEO FOOTAGE FREE OF CHARGE FOR MARKETING PURPOSES.