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Consent For NeoGen Plasma
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Name
*
First
Last
Last 4 Characters Of IC
Gender
Male
Female
Patient Safety (Please complete the following section by marking a “X” if applicable. Where applicable, please provide additional details that would allow the therapist to better understand your medical history)
Pacemaker/ defibrillator
Metal implants
Current or history of skin cancer/ other cancer/ pre-malignant moles
Severe concurrent medical conditions (eg. Cardiac disorders)
Pregnancy and nursing
Impaired immune system
Diseases stimulated by light (eg. Lupus, Porphyria, Epilepsy)
Diseases stimulated by heat (eg. Herpes Simplex)
Endocrine disorders (eg. Diabetes, PCO)
Surgical Procedures last 3 months
Injections / Fillers
Facial laser resurfacing/ deep chemical peeling, last 3 months
Use of medication/ herbs inducing photosensitivity
Sapheneous Insufficiency
Needle epilation, waxing or tweezing (last 6 weeks)
Skin Disorders (eg. Keloids, abnormal wound healing)
Active skin infection (eg. Psoriasis, eczema)
History of bleeding disorders
List any medications taken , Allergies Etc
Patient Advice: Dermatological treatments are aimed at eliminating blemished areas from the skin, improve lines and irregularities that result from the aging process/sun damage, and allow the recipient to experience normal healthy skin following treatment. (i. Precautions before Neogen Plasma Treatment)
Do not drink alcohol, take aspirin, ibuprofen, vitamin E or fish oils for three days prior to, and 3-5 days after your treatment. Using these may increase the likelihood of bruising.
Avoid direct exposure to the sun
A sunscreen of SPF30 or greater should be used when exposed to the sun for several months before and after your treatment, or as long as you plan to continue treatment. Darker melanin or pigment from the sun may produce side effects or make the treatment less effective.
The treated area may show a reddish/bruised discoloration. This will last 5-14 days, depending on what part of the body is treated. The treated area is delicate and should be treated with care. Please read and follow these instructions.
Discomfort or stinging may be evident, but usually lasts no more than six hours. Panadol may be taken (as per recommended dosage) or cool packs applied during this period. If swelling occurs, cool compresses may be applied
If a crust or scab develops, allow it to fall off on its own. Do not pick or scratch at the area. Keep the area moist with the ointment until the crust falls off.
Showering is permitted. Do not soak in a hot tub until the area is healed. Do not rub the treated area with a face cloth or towel. Pat the area dry so the skin is not disturbed
If bruising is present, please avoid swimming and sports to reduce skin irritation and infection
Do not apply make-up for 2-3 days, or as long as the crusting is present.
I Duly Authorize The Therapist To Perform The Treatment Procedure On Me.
I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre/post treatment instructions, and individual response to treatment.
I understand that there is a possibility of short-term effects such as reddening, mild burning, temporary bruising and temporary discoloration of the skin, as well as the possibility of rare side effects such as scarring and permanent discoloration.
I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained.
I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.
I confirm that I have informed the staff regarding any current or past medical condition, disease or medication taken.
I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.
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