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Plamere Plasma Consultation and Consent Form
It is imperative that you discuss any areas of this form that you do not understand, or any concerns you may have, with the practitioner prior to treatment. It is your responsibility to fully understand the procedure and expected outcomes before the treatment starts.
Ensure all points below have been fully discussed and understood. When ticking each statement, you are stating that you understand and accept the terms of this treatment.
Please read carefully and sign ONLY if/when you feel comfortable to proceed.
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| You have chosen a cosmetic procedure that is not medically necessary. |
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| Plamere Plasma is an art process-not an exact science- and can not guarantee an exact shrinkage result due to individual skin elasticity and healing process. |
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| You may be required to return for additional treatments before your overall procedure is deemed complete. The payment and time frames for any additional work will be discussed and agreed upon prior to the treatment commencing. Dependent on the area of treatment, additional treatments can not be performed sooner than 4 weeks or later than 8 weeks after the initial and subsequent visits. It is imperative for the area to fully heal prior to additional treatments. |
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| A treatment plan record will be kept by your practitioner to record area’s you have chosen, anaesthetic used as well as pre and post treatment photos. |
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| The skin type of each guest is different and the healing process may lead to mild discoloration of the skin. Microdermabrasion treatments may be suggested after the healing process is complete. |
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| After each treatment, swelling and redness may occur. Some guests may experience extreme swelling. You will be given advice on how to reduce and minimise the risk. |
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| The treatment includes a small burn to the skin, you may experience a smell of charring. This is completely normal. |
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| You must adhere strictly to the specific aftercare advice provided to you following your treatment. Doing so is extremely important and will greatly reduce the risk of post procedural infection upon leaving the Clinic. |
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| Treated area must heal properly. Picking, plucking, scrubbing or manipulating the treatment area could make the treatment area appear uneven, discolored or scarred, requiring further work. |
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| Beware that cosmetic or medical skin altering procedures such as plastic surgery, implants, injectables and weight loss or gain may alter the Plamere Plasma treatment look. |
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I consent to photographs being taken before, during and after each procedure. I agree to these photos being stored electronically in my case file and will be used only with my written consent for promotional purposes.
Tap or click on the signature above to sign
I have undergone or been offered an allergy test prior to my initial treatment. I therefore release the practitioner from liability related to any allergic reaction I may experience associated with either the application of the pretreatment cream or any other products used before during and after my procedure immediately or at a later date.
Tap or click on the signature above to sign
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If you have ANY of the following conditions, Plamere Plasma Treatment will NOT be suitable for you. Please discuss with your practitioner if you are unsure of any of the mentioned conditions.
- Critical thrombocytopenia (low platelet count)
- Hypofibrinogenaemia
- Haemodynamic instability (collapse)
- Sepsis (infection)
- Acute and chronic infections
- Chronic liver disease
- Anticoagulation therapy (warfarin, dabigatran, heparin)
- A medical condition that could worsen or spread with injections, such as an active infection, a metastatic disease, or certain skin diseases
- Blood disorders and/or platelet abnormalities
- Anemic
- Pregnant or breastfeeding
Plamere Plasma will NOT be suitable for you.
Please continue with the form.
Fitzpatrick Skin Types:
1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker
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I understand that the Practitioner will be in direct contact with me in relation to my Plamere Plasma Treatment. All other equipment is sterilized before use, all surfaces involved in the process are clean and protected and the treatment involves use of a disposable probe. The practitioner will also be wearing single use disposable gloves and mask during my procedure.
I understand the importance of my accurate and complete medical history.
I understand withholding any medical information may be detrimental to my health and safety during, and after the treatment.
I understand that if there is any change in my medical history it is my sole responsibility to inform the practitioner.
I hereby consent to receiving a plamere plasma tightening treatment. The practitioner has explained the terms and conditions of the treatment and I have fully understood these. I hereby give written consent to the practitioner, who has been fully trained, to carry out the treatment of my choice as requested by me on this consent form.
Tap or click on the signature above to sign
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Appointment Guidance
- Please only attend at your appointment time
- Please ensure you are on time - if you are late this may result in your appointment being cancelled
- Please attend your appointment unaccompanied
- Please limit the personal possessions you bring with you
- Hand sanitiser will be provided upon arrival and will be available throughout your appointment
- Please wear a face covering to enter and walk around the salon/clinic
- We encourage contactless/card payments where possible
- If you experience Covid-19 symptoms after your appointment please contact us immediately
Please DO NOT attend your appointment. Please contact us to cancel / reschedule.
Please DO NOT attend your appointment. Please contact us to cancel / reschedule.
Data Protection and Privacy
We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at any time to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.
