Plasma Pen Consultation Consent Form

PLASMA PEN CONSULTATION & CONSENT FORM (TEMPLATE)

A ready-to-use consultation and consent form template for salons and clinics offering plasma pen (fibroblast) treatments. Covers everything a technician needs to confirm a client's suitability and document informed consent before treatment.

Download Consent Form (PDF)

WHAT'S INCLUDED

• Client & contact details section
• Plain-language explanation of the treatment, healing timeline, and realistic expectations
• A 16-question medical history & suitability questionnaire covering pregnancy, allergies, blood thinners, autoimmune conditions, cardiovascular history, cancer history, and more
• Fitzpatrick skin type assessment, with guidance on which skin types are suited to full-strength treatment
• Photo/video and patch-test consent sections
• Client and technician signature blocks

HOW TO USE IT

Print it for in-person consultations, or adapt it into your own digital intake form. Walk through every question with your client, record their skin type assessment, and have both parties sign before treatment begins.

IMPORTANT

This is a general template for salon and clinic use, not legal advice. Have it reviewed by a qualified lawyer or your professional indemnity insurer in your jurisdiction before using it with clients.

FAQ

Is this form legally binding on its own?

A signed consent form supports your documentation but doesn't replace proper legal review. Have it checked by a lawyer or your indemnity insurer for your specific location before relying on it.

Can I customize this template for my salon?

Yes — it's designed as a starting template. Adjust branding, add any location-specific regulatory language, and adapt the questionnaire if your local board requires additional disclosures.