Fibroblast Plasma Full Consent Form

Ultraformer MPT Patient Consent Form

CLIENT DETAILS

Full Name(Required)

Date of Birth

Address

Street Address

Phone

Emergency Contact

Relationship

Emergency Contact Phone

Treatment Date

Practitioner

MEDICAL HISTORY

Pregnant or Breastfeeding?

Yes

Pacemaker or implanted electrical device?

Yes

Epilepsy or seizures?

Yes

Keloid or hypertrophic scarring?

Yes

Diabetes?

Yes

Autoimmune disease?

Yes

Cancer (current or previous)?

Yes

Blood clotting disorder?

Yes

Heart condition?

Yes

Herpes Simplex (cold sores)?

Yes

Skin infection or open wound?

Yes

Recent surgery?

Yes

History of pigmentation issues?

Yes

Current medications?

Yes

Roaccutane/Accutane within past 12 months?

Yes

Known allergies?

Yes

Smoking/Vaping?

Yes

Current Medications

Allergies

Additional Medical Information

SKIN ASSESSMENT

Fitzpatrick Type

III

Skin Condition

Normal

Dry

Oily

Combination

Sensitive

Treatment Area(s)

Primary Concern(s)

Details

PRE-TREATMENT CHECKLIST

Pre-Treatment Checklist(Required)

No sun exposure, solarium or fake tan for 2 weeks prior

No Retinol, AHA/BHA acids or exfoliation for 7 days prior

No Botox or fillers in treatment area within previous 3–4 weeks

No active infection in treatment area

No alcohol or blood thinning supplements 48 hours prior

Arrived with clean skin free from makeup and sunscreen

Practitioner informed of all medications and medical conditions

About Fibroblast Plasma

Fibroblast Plasma is a non-surgical skin tightening procedure that creates controlled micro-injuries on the skin surface using plasma energy.

The treatment stimulates collagen production, tissue contraction and natural healing processes.

Results vary between individuals. Multiple treatments may be required and no specific outcome can be guaranteed.

RISKS & POSSIBLE SIDE EFFECTS

Risks & Possible Side Effects Acknowledged(Required)

Results vary between individuals and cannot be guaranteed

More than one treatment may be required

Swelling may last 2–14 days

Redness may last several days to weeks

Small crusts will form and naturally fall away within 5–10 days

Temporary pigmentation changes may occur

Temporary hyperpigmentation may occur

Temporary hypopigmentation may occur

Rare risks include infection

Rare risks include scarring

Rare risks include prolonged redness

Rare risks include prolonged swelling

Rare risks include delayed healing

Rare risks include unsatisfactory cosmetic outcome

Full collagen remodelling may take 3–6 months

Smoking, sun exposure and poor aftercare may affect results

PHOTOGRAPHY & VIDEO CONSENT

Photography & Video Consent(Required)

Treatment Records Only

Progress Monitoring

Training & Education

Website

Social Media

Marketing Material

Full Consent

I Do Not Consent To Marketing Use

Client Initials

PRIVACY CONSENT

I consent to Bayside Endermologie Health & Wellness collecting, storing and using my personal and health information for consultation, treatment, record keeping, insurance, legal compliance and communication purposes in accordance with the Australian Privacy Principles.

Privacy Consent(Required)

I Consent

PAYMENT POLICY

Payment is required on the day of treatment unless otherwise agreed in writing.

Payment Policy(Required)

I Understand

CANCELLATION POLICY

A minimum of 24 hours notice is required for cancellation or rescheduling. Failure to provide adequate notice may result in loss of deposit or cancellation fee.

Cancellation Policy(Required)

I Understand

REFUND POLICY

Due to the nature of aesthetic procedures, results vary between individuals and cannot be guaranteed. Completed treatments are not refundable. This policy does not exclude rights under Australian Consumer Law.

Refund Policy(Required)

I Understand

COMPLAINTS POLICY

If you have concerns regarding your treatment, please contact Bayside Endermologie Health & Wellness. Complaints will be investigated promptly and responded to within a reasonable timeframe.

Complaints Policy(Required)

I Understand

AFTERCARE INSTRUCTIONS

Aftercare Instructions Acknowledged(Required)

Keep treated area clean and dry

Allow crusts to fall off naturally

Avoid scratching or picking

Avoid swimming, sauna, gym, steam rooms and excessive sweating until healed

Avoid makeup until crusting has resolved

Avoid direct sun exposure

Wear SPF50+ daily once skin has healed

Avoid active skincare products for 2 weeks

Contact practitioner immediately if signs of infection occur

TREATMENT RECORD

Topical Products Applied

Treatment Notes

Practitioner Recommendations

CLIENT CONSENT & SIGNATURES

Client Consent(Required)

I have read and understood the information provided.

I understand the risks, benefits and limitations.

I understand results vary and cannot be guaranteed.

I understand additional treatments may be required.

I have had the opportunity to ask questions.

I voluntarily consent to treatment.

Client Signature(Required)

Date

PRACTITIONER DECLARATION

I confirm I have assessed the client, reviewed contraindications, discussed risks, benefits and aftercare instructions and believe the client is suitable for treatment.

Practitioner Signature

Date

CLIENT DETAILS

MEDICAL HISTORY

SKIN ASSESSMENT

PRE-TREATMENT CHECKLIST

RISKS & POSSIBLE SIDE EFFECTS

PHOTOGRAPHY & VIDEO CONSENT

PRIVACY CONSENT

PAYMENT POLICY

CANCELLATION POLICY

REFUND POLICY

COMPLAINTS POLICY

AFTERCARE INSTRUCTIONS

TREATMENT RECORD

CLIENT CONSENT & SIGNATURES

PRACTITIONER DECLARATION

Contact Info

Useful Links

Our Treatments

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