Healthcare Plasma Pen Consent Form

HEALTHCARE PLASMA PEN CONSENT FORM

Patient Information

Date of Birth:    Gender:    Phone:

Relationship:    Phone:

Insurance Information (if applicable)

Policy Number:    Group Number:    Subscriber Name:

Medical History and Current Health

Please check any of the following that apply:

History of bleeding disorder or current anticoagulant therapy
Pregnant, planning pregnancy, or breastfeeding
Cardiac pacemaker or implanted electronic device
Immunosuppressive therapy or organ transplant recipient
Use of isotretinoin (Accutane) within past 6 months
History of abnormal scarring or keloid formation

Procedure Description, Risks and Benefits

Description of Procedure: I authorize the performance of plasma pen treatment to the following area(s): . The procedure uses controlled plasma energy to create microthermal zones to tighten and resurface skin.

Expected Sessions: . Benefits: improvement in skin laxity, texture, and appearance. Results vary and are not guaranteed.

Possible Risks and Complications (not all inclusive): pain, redness, swelling, blistering, scabbing, infection, hypo- or hyperpigmentation, prolonged erythema, scarring, allergic reaction to topical products, delayed healing, or need for additional corrective procedures. If infection or scarring occurs, further medical treatment may be required.

Alternatives: defer treatment, topical therapies, lasers or surgical procedures. I acknowledge that my practitioner has explained alternatives and answered my questions.

Pre-Procedure and Aftercare Instructions

Pre-procedure instructions include avoiding sun exposure and tanning, discontinuing certain blood-thinning supplements or medications when medically appropriate, and disclosing all medications. I acknowledge I have received verbal and written pre- and post-care instructions and understand that failure to follow instructions may increase the risk of complications.

I acknowledge that I have been advised to avoid the following prior to treatment: Recent tanning or sunburn    Blood-thinning medications/supplements (as directed by provider)

Photography and Records

I consent to clinical photographs for medical record keeping and for use in practitioner education and marketing only if I give consent below. I understand identifying information will be protected unless I sign a separate release.

I consent to before-and-after photographs for the purposes described above.

HIPAA and Privacy Acknowledgment

I acknowledge receipt of the provider's privacy practices and consent to the use and disclosure of my protected health information for treatment, payment, and health care operations as required for my care.

I acknowledge that I have received and reviewed the privacy practices.

Authorization and Certification

By signing below I certify that I am the patient or authorized representative, that I am at least 18 years of age (or guardian/parent signing with relationship specified), and that the information provided is true and complete to the best of my knowledge. I authorize the provider and clinical staff to perform the plasma pen procedure described above and such additional acts as may be necessary for my care. I understand that no guarantee has been made as to the results of the procedure.

I understand I may withdraw consent at any time prior to the initiation of the procedure by verbal notice to the provider. I release the provider and clinic from liability for complications or adverse outcomes except as a result of negligence or willful misconduct.

Authorization expiration date (this consent will expire on the date below unless earlier revoked):

Patient Acknowledgments (Initials)

Initial to confirm: I understand the risks and have had the opportunity to ask questions and receive satisfactory answers.

Initial to confirm: I have disclosed all medications, supplements, and medical history relevant to this treatment.

Initial to confirm: I understand the post-care instructions and the need to avoid sun exposure until fully healed.

Additional Notes

Sign Now