Plasma IQ Patient Consent

IMPORTANT:

The following language is provided to assist you in developing your personalized PLASMA IQ™ general consent.

INTENDED USE / INDICATIONS

PLASMA IQ is used in the removal and destruction of skin lesions and coagulation of tissue.

PLASMA IQ™

PLASMA IQ is a minimally invasive, ablative procedure that will be performed using FDA 510k-cleared equipment and best practice safety and hygiene techniques to rejuvenate and tighten skin and reduce the signs of aging.

How PLASMA IQ Works

PLASMA IQ treatment harnesses the power of plasma energy to create small thermal wounds at the skin surface that extend deep enough (into the upper dermis) to rejuvenate and tighten skin and reduce the signs of aging. Fibroblasts, collagen, and elastin fibers are located in the dermal layer.

Providers cannot guarantee a measured tightening result due to individual skin condition at the time of treatment, including degraded collagen content and reduced skin elasticity as well as the individual healing process, your age, health and lifestyle. Achieving best results may require more than one treatment. After initial healing, a subsequent treatment may be performed, if necessary, 8 to 12 weeks later.

Procedure Description

PLASMA IQ treatment involves the use of a local anesthetic, either topical or injected, for pain control. Immediately after treatment, brown dots (carbon crusts) will be visible for approximately 5 to 7 days following your procedure. In rare cases, these brown dots may desquamate (flake off) and be replaced with pink markings while the skin is regenerating. This may last for up to 8 weeks and will typically resolve naturally as the skin heals below the surface. Minor swelling of the treatment areas and surrounding skin may be present for a few days after treatment and bruising may occur from the local anesthetic injections. The skin in the treatment area(s) may be pink for several weeks but patients with lighter skin complexions may have redness that lasts for several months before finally fading.

CONTRAINDICATIONS

Birthmarks and Port-wine Stains
Warts
Tattoos
Blood Coagulation (Hemophilia)
Auto-immune disorders (Lupus)
Fitzpatrick Skin Types IV, V, VI
Patients with an implanted pacemaker
Patients with metal or electrically conductive implants
Cancer
Eye regions/eyelids
Pregnancy and breastfeeding
Cardiac Disorders
Cardiovascular Diseases
Uncontrolled Diabetes
Circulatory Disorders
Active Herpes or Shingles
Skin Disorders including psoriasis, eczema, dermatitis, Vitiligo
Scars including hypertrophic, keloid scars or previous occurrences of keloid scars

PRECAUTIONS
Consult with the patient on the following: Toxins, chemical peels, retinols, and/or dermal fillers in the treatment area Topical Anesthetic Intolerance Recent surgical procedures Hyperpigmentation Uncontrolled Epilepsy Anemia Medications or herbal supplements Eye conditions or prior surgeries/treatments

Note: contact lens use during and after procedure is not recommended.

POTENTIAL SIDE EFFECTS

Possible complications of PLASMA IQ treatment are similar to other types of skin resurfacing procedures and include delayed healing, scarring, swelling, redness and skin discoloration. PLASMA IQ technology is to be used in patients with light to medium skin complexions. The risk for skin discoloration may be higher in patients with darker skin.

PRE-CARE RECOMMENDATIONS

Avoid sun exposure or tanning beds for 2-4 weeks before treatment.
Ideally, begin applying sunscreen for 2-4 weeks before treatment.

POST-CARE RECOMMENDATIONS

There may be stinging in the treated area immediately following treatment. This is normal and typically lasts for about an hour, but some variation in time may occur.
DO NOT pick at or scratch at scabs during the healing phase, which typically lasts 5-7 days. This may delay healing or affect outcomes.
Avoid touching or cleansing the area for at least 12 hours after the procedure. In case of infection, consult with your physician.
Continue to apply moisturizer or occlusive balm (e.g. petroleum jelly) during the healing phase twice daily after gentle cleansing.
Avoid sunlight, exercise, heat, steam, or sweat for 48 hours after the procedure. After 48 hours, apply sunscreen to the treated area daily.
DO NOT use makeup or products other than sunscreen/moisturizer/occlusive balm on the treated area until scabs have fallen off.

IMPORTANT: Please also review the product label in consultation with your treating physician.

Any potential complications related to energy-based treatments:

Swelling and Bruising
Skin discoloration
Redness and tenderness
Scarring
Scabbing and crusting
Infection
Concomitant procedures

Guarantees

Setting realistic expectations
Expected outcomes and potential need for multiple treatments

Before and After Photos Consent

Refund/Payment Consent

CONSENT TO TREATMENT

I have carefully read and understand this consent in its entirety, and I have discussed the benefits and risks of treatment with my physician or his or her representative.

It is important that you read the above information carefully and have all of your questions answered before signing.

I consent to treatment and understand that there are potential risks to this treatment and that there are alternatives to this treatment. I also understand that this consent is valid for future treatments unless the policies of the office or the known risks for the product change. By signing this form I acknowledge that guarantees as to the final results of my treatment have not been made. Additionally, I agree to have my photos taken to be used for documentation purposes.

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Patient Signature(Required)

Date(Required)