Please read. A hard copy will be ready to complete/sign at your first appointment. Please message me with any questions!

Medical History and Consent

Full Name ______________________________________________________________________ Date_______________________ Email____________________________________________

Phone (______)_________________________

Mailing Address (optional): ____________________________________________

Who may I thank for your referral? ________________________________________

Current Medications (please list) _______________________________________________

Have you taken Accutane within the last year? Y / N __________________________

List any Allergies ____________________________________________________________

What concerns would you like to address?_____________________________________________

Please Read Carefully - Have you had or do you currently have any of the following?

Check any that apply

____Cancer ____Cold Sores ____Contact Lenses ____Hemophilia ____Dermatitis / Eczema

____Diabetes _____Insulin dependent ____Latex Sensitivity / Allergy ____Keloid Scar

____ Epilepsy ____Problems with Healing ____Tattoo / Permanent makeup ____

____ Chemical peels ____Laser Resurfacing ____Pregnant / Nursing ____Plasma Pen Treatment

_____ Hyperpigmentation _____ Melasma ______ Cosmetic Surgery _______ Lash Extensions

_____ No Botox in the last two weeks ______No Injectable Fillers in the last two weeks

____ Pacemaker______ Electrical implant with slow release medication

* If you suffer from any of the above, it is important that you notify your technician so that they can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health.

Additional Notes: _________________________________________________________________________________

PLEASE READ CAREFULLY AND INITIAL / SIGN WHERE INDICATED.

Ensure all points below have been discussed with the technician. You are signing to state tha4t you understand and accept these terms.

1. I acknowledge that any information contributed by me is true, to the best of my knowledge and that the present condition of the area that has been or will be treated is stated on this record. I fully understand that Mary Jordan/Just Jet Plasma LLC, provides Jet Plasma/Light Therapy services. There is no medical treatment involved. Jet Plasma Treatment is an art - not an exact science - and cannot guarantee an exact shrinkage result due to skin elasticity and individuality which includes client”s health, genetics, lifestyle factors and following proper aftercare. (Initials)______

2. I understand that Jet Plasma requires sessions, minimum 4 suggested for best results and that I may be required to return for additional treatments before the overall procedure is deemed complete. The payment for any additional work, (if applicable), will be agreed prior to the treatment commencing. Depending upon area of treatment, additional treatments cannot be performed until 6-8 weeks after 8 sessions in the same area to allow sufficient healing time/cell turnover. (Initials)______

3. I realize that with any beauty service there may be certain risks, which must be understood. I will be fully responsible for any and all results, which may arise from these beauty services. I do hereby agree to hold Mary Jordan/Just Jet Plasma LLC, free from any and all claims or suits for damage, for injuries or complications resulting from any beauty services provided by Mary Jordan/Just Jet Plasma LLC. (Initials)______

4. The skin type of every client is different and although Jet Plasma is safe for all Fitzpatrick, it is important you follow aftercare instructions. Additional sessions may be advised after the healing process is complete. (Initials)______

5. I understand that taking before and after photographs of the said procedures is a requirement of such procedure. I grant permission for the use of the photographs, or electronic media images as identified, in any presentation of all kinds.

(Initials)______

6. I have received pre and post procedure instructions and will strictly adhere to them. I understand that my failure to do so may jeopardize my chances for a successful outcome.

(Initials)______

7. I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medical history it is my responsibility to inform the technician. (Initials)______

8. I am aware that any skin altering procedures such as laser treatments, plastic surgery, implants, injectables and weight gain or loss may alter the treatment’s look. (Initials)______

I, the client, agrees with all points listed and discussed, and wish to proceed as recorded with procedure with Mary Jordan/Just Jet Plasma LLC. I participated fully in the decision for the selected area or areas intended for my Jet Plasma Pen Treatment. I certify I have read and initialed the above paragraphs. I have had it explained to my understanding therefore I consent to this procedure. I accept full responsibility for the decision to receive this treatment and do not hold Mary Jordan/Just Jet Plasma LLC responsible for any adverse reaction.

Client’s Full Name

Print____________________________________________________________________

Client Signature_____________________________________________Date_______________

Treatment Agreement

I, Mary Jordan/Just Jet Plasma LLC, confirm I have checked all paperwork including consent forms and medical history, I have discussed all procedure points with my client and they understand all elements of the Jet Plasma Pen Treatment. Aftercare advice has been verbally presented to the client and written instructions will be provided.

Technician Signature __________________________________

Date _______________________________

Consent to follow Aftercare

I_____________________________ agree to follow the aftercare I have been provided by my Jet Plasma practitioner.

Following your treatment, due to the channels in the skin being open it is important that nothing is applied to the skin for 12 hours other than what your skin care professional puts on your skin.

No makeup can be worn after treatment for 12 hours.
No exercise, sauna or steam room for 12 hours.
No tanning or spray tans for 12 hours.
My next appointment has been scheduled.

I understand if I do not follow the Aftercare Instructions I have been given I may experience a negative outcome. Minimum 4 sessions are recommended for Jet Plasma.

Signed _____________________________________________ Date ______________

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