M.U.S Beauty Lounge

Plasma Fibroblast Consultation and Consent Form

Client Details

➢Name: ______________________________________. ➢Date of Birth: __ / __ / ____
➢Email: ______________________________________ ➢Contact Number: ______________________________

Medical History

1. Are you currently taking any medication? ( circle one) YES / NO
If YES please write the name of your medication here: ________________/________________/__________________/_____________________

2. (please circle one) YES / NO

Do you have any allergies or intolerances?

3. (please circle one) 4.

o Breastfeeding
o Allergic to topical anesthetic preparations
o Currently have an infection at the treatment site o Using isotretinoin for wrinkles or acne
o Have a history of keloids
o Have a history of hypertrophic scarring

5. Do you have any other medical conditions? ? (please circle one)
If YES please write the name of your medical condition here: ________________/________________/__________________/____________________

Are you currently, or possibly may be, pregnant?

YES / NO

Do any of the following apply to you? Please MARK all that apply:

6. Have you recently been unwell? ? (please circle one) YES / NO

YES / NO

Emergency Contact Details

1.Emergency Contact Name:_______________________

2. Emergency Contact Relationship:

o Husband
o Wife
o Partner
o Mother Father o Aunt

o Uncle
o Friend
o Other:____________

3. Emergency Contact Phone: ______________________

Consultation

1. What are your main skin concerns?

2. What are your goals and expectations of the treatment?

BY MONICA NGUYEN

M.U.S Beauty Lounge

3. 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

Which of the above skin types would you say is closest to your skin ? Please circle number :__ 1___ 2___3___4___5___6____

Treatment Information

What is Plasma Fibroblast?

Plasma fibroblast therapy targets fibroblasts. These are collagen and protein-producing cells in the dermis, the layer of skin just below your outermost skin layer. Fibroblasts play an important role in helping skin wounds heal as well as maintaining skin firmness and tightness.
Plasma fibroblast therapy uses a pen-like device that discharges a high-frequency electric current to small areas of the skin. The plasma tip doesn’t directly touch the skin, but instead releases a targeted current just above the skin. The hot current creates small holes, or micro-injuries, in the skin’s layer.
Also we call this approach plasma skin resurfacing.
Plasma fibroblast therapy may be used to treat the following conditions:

✓ Acne scars
✓ Photo aging, including age spots
✓ Seborrheic keratosis
✓ Wrinkled skin, including the eyelids, neck, jawline, and above the lips

Possible Side Effects

The Plasma Fibroblast treatment will produce side effects after the procedure. This is common and normal.

➢ Side effects expected include:
Redness, Swelling, Mild hypopigmentation (light spots),

Mild hyperpigmentation (dark spots), Skin peeling and crusting.

BY MONICA NGUYEN

M.U.S Beauty Lounge

Eye Treatment Area

Day of treatment: Some swelling. Feels hot like a sunburn. This feeling can last for up to 3 hours +
Day 1 (Next day post-treatment): Lots of swelling (the most swelling), especially in the morning.
Day 2: Swelling.
Day 3: Itchy sensation and tightness. Swelling decreases. Dots dry and may start to fall

off.

Swelling

You will notice most of the swelling on the first morning after treatment, particularly around the eyes. Swelling usually lasts two to three days. To minimize swelling try the following:

Follow Lymphatic Drainage Protocols
Avoid salt and alcohol

Heat/Sunburn/Stinging

Feeling hot like a sunburn stinging sensation is normal immediately after the treatment and for the rest of that night.

Itchiness

You will start to feel itchy from the 3rd day. Do not pick at the dots. The itchiness sensation means that the dots are starting to heal and are getting ready to dry and fall off.

Dry skin

Your skin may feel dry, peel or flake. You may notice a “sandpaper” texture a few days after treatment. This is the treated tissue working its way out of your body as new fresh skin is regenerated.

Redness

BY MONICA NGUYEN

M.U.S Beauty Lounge

Most redness resolves during the first week after treatment, but a rosy “glow” can remain for several weeks. After the carbon crusts (dots) have fallen off, 5 to 7 days after the treatment, that’s when you can apply your normal coverage of makeup.

Bronzing, Crusting and Small Dark Dots

The treatment causes destruction to microscopic cylinders of skin which then exfoliates during the healing process. The treatment can make the skin look bronzed, or small areas appear crusted (do not try to scratch them off). Scratching off any carbon deposits (dots) may result in infection, scarring and hypo-pigmentation of the skin that may not be able to be reversed. Please refrain from scratching any areas that are healing.

Raw Skin

If you develop areas of raw skin post treatment, you do not need to apply band-aids, but keep the areas moist and do not pick at them. They will heal very rapidly on their own and without problems.

Weeping

Initially, after treatment and for a day or so afterward, there may be occasional weeping (yellow pus). This is simply plasma and is a natural healing response. This simply flakes off after a few days but in some cases can take over 1 week.

BY MONICA NGUYEN

M.U.S Beauty Lounge

Aftercare

Please read carefully.

For 1 week after treatment

Wash the area gently with water, carefully pat dry.
Apply aftercare cream. We can advise you on the best type of cream to use.
No makeup
No swimming
Do not use Actives or Anti-Ageing Creams (Retinols, Tretinoin, Retin A)
No sauna
No exposing the area to sunlight

For 2 weeks after treatment

Moisturizer the area twice a day, using products that are hydrating and repairing. Ingredients such as Hyaluronic Acid and Canella help heal the skin as well as hydrating it.
Gentle cleansing
Do not use AHA’s, Glycolics or Retinols
Do not use exfoliating products

At all times during treatment

Sun exposure should be avoided.
Moisturize the area twice a day, using products that are hydrating and repairing.

Ingredients such as Hyaluronic Acid and Centella help heal the skin as well as hydrating

it. You want to ensure that the skin is prevented from drying out and peeling.
No sunbeds or tanning/sunbathing

Skin Care Products by M.U.S BEAUTY LOUNGE

All your skin care products should be non-irritating and non-clogging for the first week or so after the treatment. For the best results, we advise using products that contain healing and hydrating ingredients such as Hyaluronic Acid and Centella. Do not use abrasive scrubs, toners,

6

BY MONICA NGUYEN

M.U.S Beauty Lounge

or products that contain glycolyic acids or Retin A. Read the product labels if you are unsure. Resume your normal skin care regimen only when your skin has fully healed.

Sunscreen

You should not apply sunscreen. If direct sun exposure is necessary, wear a hat and clothing that covers the treated area. Use this regimen during the healing period and always.

Moisturizers

Remember that peeling and/or flaking is normal during the healing process. Therefore, the product should be non-irritating and non-clogging, or else you could develop breakouts. During the healing period your normal moisturizer may be too occlusive. The M.U.S BEAUTY LOUNGE can advise you on the best type of moisturizer to use. Reapply whenever your skin feels dry.

Cosmetic Treatments

Do not healed.

• • • • • • •

have any of the following cosmetic treatments on the treated area until the skin is fully

Skin Needling
Laser Hair Removal
Laser Carbon Peel
PRP
Botox/Fillers
BB Glow
Active Peels (AHA, Enzyme, etc)

Please seek advice from M.U.S BEAUTY LOUNGE before having any other cosmetic treatments whilst your skin is still healing.

Please CHECK the box to confirm:

I have read and understood the aftercare advice given to me on this form.

Consent

BY MONICA NGUYEN

M.U.S Beauty Lounge

Please read each statement carefully and CHECK to show your agreement.

o o o

o o

I accept that any treatment I am going to receive is at my own risk.
I certify that I have read and fully understood and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.
I accept that if I am not satisfied with the treatment, I will inform the therapist and/or request to speak to the manager M.U.S BEAUTY LOUNGE during or immediately following the treatment.
I fully understand the above and consent to receive a Plasma Fibroblast Treatment

Client Signature : __________________________________DATE____/_____/________

___________________________________________________________________________________

BY MONICA NGUYEN

M.U.S Beauty Lounge

M.U.S BEAUTY LOUNGE USING THIS PART

BY MONICA NGUYEN

Emergency Contact Details

1.Emergency Contact Name:_______________________ 2. Emergency Contact Relationship:

o Husband
o Wife
o Partner
o Mother Father o Aunt

o Uncle
o Friend
o Other:____________

3. Emergency Contact Phone: ______________________

Consultation

1. What are your main skin concerns?

2. What are your goals and expectations of the treatment?

BY MONICA NGUYEN

M.U.S Beauty Lounge

3. Fitzpatrick skin types:

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

Treatment Information

What is Plasma Fibroblast?

Plasma fibroblast therapy targets fibroblasts. These are collagen and protein-producing cells in the dermis, the layer of skin just below your outermost skin layer. Fibroblasts play an important role in helping skin wounds heal as well as maintaining skin firmness and tightness.
Plasma fibroblast therapy uses a pen-like device that discharges a high-frequency electric current to small areas of the skin. The plasma tip doesn’t directly touch the skin, but instead releases a targeted current just above the skin. The hot current creates small holes, or micro-injuries, in the skin’s layer.
Also we call this approach plasma skin resurfacing.
Plasma fibroblast therapy may be used to treat the following conditions:

✓ Acne scars
✓ Photo aging, including age spots
✓ Seborrheic keratosis
✓ Wrinkled skin, including the eyelids, neck, jawline, and above the lips

Possible Side Effects

The Plasma Fibroblast treatment will produce side effects after the procedure. This is common and normal.

➢ Side effects expected include:
Redness, Swelling, Mild hypopigmentation (light spots),

Mild hyperpigmentation (dark spots), Skin peeling and crusting.

BY MONICA NGUYEN

M.U.S Beauty Lounge

Eye Treatment Area

Day of treatment: Some swelling. Feels hot like a sunburn. This feeling can last for up to 3 hours +
Day 1 (Next day post-treatment): Lots of swelling (the most swelling), especially in the morning.
Day 2: Swelling.
Day 3: Itchy sensation and tightness. Swelling decreases. Dots dry and may start to fall

off.

Swelling

You will notice most of the swelling on the first morning after treatment, particularly around the eyes. Swelling usually lasts two to three days. To minimize swelling try the following:

Follow Lymphatic Drainage Protocols
Avoid salt and alcohol

Heat/Sunburn/Stinging

Feeling hot like a sunburn stinging sensation is normal immediately after the treatment and for the rest of that night.

Itchiness

You will start to feel itchy from the 3rd day. Do not pick at the dots. The itchiness sensation means that the dots are starting to heal and are getting ready to dry and fall off.

Dry skin

Your skin may feel dry, peel or flake. You may notice a “sandpaper” texture a few days after treatment. This is the treated tissue working its way out of your body as new fresh skin is regenerated.

Redness

BY MONICA NGUYEN

M.U.S Beauty Lounge

Bronzing, Crusting and Small Dark Dots

Raw Skin

If you develop areas of raw skin post treatment, you do not need to apply band-aids, but keep the areas moist and do not pick at them. They will heal very rapidly on their own and without problems.

Weeping

BY MONICA NGUYEN

M.U.S Beauty Lounge

Aftercare

Please read carefully.

For 1 week after treatment

Wash the area gently with water, carefully pat dry.
Apply aftercare cream. We can advise you on the best type of cream to use.
No makeup
No swimming
Do not use Actives or Anti-Ageing Creams (Retinols, Tretinoin, Retin A)
No sauna
No exposing the area to sunlight

For 2 weeks after treatment

Moisturizer the area twice a day, using products that are hydrating and repairing. Ingredients such as Hyaluronic Acid and Canella help heal the skin as well as hydrating it.
Gentle cleansing
Do not use AHA’s, Glycolics or Retinols
Do not use exfoliating products

At all times during treatment

Sun exposure should be avoided.
Moisturize the area twice a day, using products that are hydrating and repairing.

Ingredients such as Hyaluronic Acid and Centella help heal the skin as well as hydrating

it. You want to ensure that the skin is prevented from drying out and peeling.
No sunbeds or tanning/sunbathing

Skin Care Products by M.U.S BEAUTY LOUNGE

All your skin care products should be non-irritating and non-clogging for the first week or so after the treatment. For the best results, we advise using products that contain healing and hydrating ingredients such as Hyaluronic Acid and Centella. Do not use abrasive scrubs, toners,

6

BY MONICA NGUYEN

M.U.S Beauty Lounge

or products that contain glycolyic acids or Retin A. Read the product labels if you are unsure. Resume your normal skin care regimen only when your skin has fully healed.

Sunscreen

You should not apply sunscreen. If direct sun exposure is necessary, wear a hat and clothing that covers the treated area. Use this regimen during the healing period and always.

Moisturizers

Cosmetic Treatments

Do not healed.

• • • • • • •

have any of the following cosmetic treatments on the treated area until the skin is fully

Skin Needling
Laser Hair Removal
Laser Carbon Peel
PRP
Botox/Fillers
BB Glow
Active Peels (AHA, Enzyme, etc)

Please seek advice from M.U.S BEAUTY LOUNGE before having any other cosmetic treatments whilst your skin is still healing.

Please CHECK the box to confirm:

I have read and understood the aftercare advice given to me on this form.

Consent

BY MONICA NGUYEN

M.U.S Beauty Lounge

Please read each statement carefully and CHECK to show your agreement.

o o o

o o

I accept that any treatment I am going to receive is at my own risk.
I certify that I have read and fully understood and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given.

The treatment(s) and possible side effect(s) have been fully explained to me.

Client Signature : __________________________________DATE____/_____/________

___________________________________________________________________________________

BY MONICA NGUYEN

M.U.S Beauty Lounge

M.U.S BEAUTY LOUNGE USING THIS PART

BY MONICA NGUYEN

important in VIETNAMESE

NHỮNG CHÚ Ý BẠN PHẢI HIEU TRƯỚC KHI LÀM DEP TẠI MUS BEAUTY LOUNGE:

Phương pháp điều tri va chăm sóc da tai M.U.S BEAUTY LOUNGE co the chua thấy ai làm trước đây, 9 ngày đầu nên khách cần nhắc trước khi vào điều tri .
Để mang lại hiệu quả khi điều trình bắt buộc khách tuân thủ theo đúng liệu trình và thời gian chăm sóc tai M.U.S BEAUTY LOUNGE (có GIAI THICH RO cho từng loại da)
Mua thuoc them nhung loai can cho tình trang da
Da sau 6 tuần /gặp check da 1 lần
Chi phí chăm sóc khách Da trong thời gian điều trị thì các vết nám, tàn nhang, chân sâu, mảng khách phải luôn dưỡng kem cho độ hồng da và đây là bắt buộc và phải trong thời gian khá dài nên khách cân nhắc công việc và tự sắp xêp chuyện cá nhân sao cho phù hợp vì khách phải luôn nhớ dây là điều trị bệnh không phải là chăm dưỡng thông thường nên phải tuân thủ dúng nếu không bệnh sẽ không bao giờ hêt và tôn thời gian.
Vì dễ phát sinh thêm các bênh khác và cho da yếu thêm. Nên đã quyết tâm làm thì phải đủ liều cho da và làm dúng.
Ngoài ra kem diêu trị là thuốc có chứa hàm lượng can thiết đủ ức chế nám mạnh lì, vì vậy khi dùng ở giai doạn dầu da sẽ đỏ rát, ngứa, căng da và rất dễ trầy sướt. Khách cố găng dừng gãi và có lỡ cào trầy thì cư dưỡng vết thương sẽ tự lành. Nếu ngứa đỏ qua khách liên lạc qua M.U.S BEAUTY LOUNGE đê diều chỉnh sao cho dễ chịu nhất.
Điều trị nám là dễ có nguy cơ tái phát nếu kem mà khách dùng ko đủ liều ức chế nám và dùng ko dúng. Vi vậy khi da dã dẹp thì nêu dủ điều kiện khách nên tiếp tục dùng và phải duy trì để bênh chống tái phát sau này.
Khách đã tin tưởng M.U.S BEAUTY LOUNGE nên trách nhiệm và điều tiết thuốc chinh hàm lượng cho khách tới khi da khách khoe va đẹp nhu phát do. Nên quan trọng là hiểu de dùng dúng, ko tự ý tặng giản: liêu khi chưa hỏi. Không tự ý bôi thoa bật cự thứ gì ngoài products củaM.U.S BEAUTY LOUNGE dua ví dụ như: kem chông năng,toner, tây trang, các loại kem khác, thuốc liền sẹo, mù u, nghệ tươi...
Không tự ý dưa cho người khác kem dê dánh vì kem điều trị sẽ điều tiêt thèo từng loại da và cân có sự hướng dẫn của người có kiến thức diều trị. Nếu cho tặng ai da có vấn đề khách tự chịu trách nhiệm.
Trong quá trình chăm da ko bôi bất thứ gì kể cả: nghệ, thuốc chống sẹo, thuốc bôi da liễu, các loại thuốc bôi ngoài da, thuốc bôi ngứa... khi có gì lạ báo da ngay khi cảm thấy da khó chịu
Khi dang diều trị là thời gian da cực mỏng yếu, vì vậy khi da có vấn dễ thì hãy thông báo để diều chinh, thời gian diều trị đã dươc thông báo trươc khi khách dồng ý diều trị. Nếu khách tự ý di qua nơi khác thăm khám thì coi như tự chấm dứt điều trị bên M.U.S BEAUTY LOUNGE và bên M.U.S BEAUTY LOUNGE cũng không chịu bất cứ trách nhiệm nào và cũng không thu hồi thuốc và hoàn trả bất cứ chi phí nào lại cho khách.
Khi đã diều trị khách nên hiểu ro ve thoi gian va chi phi : tiền bạc, theo dưỡng lâu dài va không đồ lỗi cho bất cư quyết dinh nào của mình.
Khách kiên trì bôi đúng dủ theo hướng dẫn là da sẽ tốt dần lên. Da moi người khác nhau nên cũng sẽ có su khác nhau ve thoi gian va chăm duong nên kiên trì dưỡng là khoe, đẹp. Còn lại đã điều trị thống nhất từ đầu,có gì thac mac thi báo để chỉnh định kì (đây là bắt buộc)
NOTE: LIỆU TRÌNH ĐA LÀ NHƯNG GÌ ĐỨC KẾT KINH NGHIỆM NHIÊU NĂM VÀ RÚT NGÂN THỜI GIAN ĐIỀU TRỊ TỔI ĐA NHẬT. KHI LÀM LIỆU TRÌNH DA Ở THỜI GIAN ĐÀU LÀ DA RÁT YÉU VÀ SẼ PHỤC HỎI DÀN TRONG QUÁ TRÌNH CHĂM DA NÊN KHÚYẾN CÁO KHÁCH TÌM HIÊU TRƯỚC KHI QUYẾT ĐINH LÀM. TRÁNH TRƯỜNG HỢP ĐÃ VÔ LÀM THÁY ĐỎ RÁT LẠI ĐI KHÁM DA LIỄU RỒI CHẠY ĐI CHỖ NÀY CHỖ KIA TRONG QUÁ TRÌNH LÀM DA SẼ RÁT BÁT TIỆN CHO CẢ ĐÔI BÊN. XÁC ĐỊNH LÀM DA LÀ PHẢI THEO IT NHÁT 1 NĂM ĐỂ DA HOÀN TOÀN ÓN ĐỊNH NÉU MUỐI CHĂM DA NƠI KHÁC ĐỂ ĐẢM BẢO DA HỎI PHỤC 1 CÁCH TỐT NHÁT.
Da sach...da dep
HIEU...THOI GIAN...TIEN...DEP

CONSENT FORM