U&I Spa Inc

Cold Plasma

130 West 57th Street, Suite 14A
New York, NY, 10019

Phone: 917.214.9910
Email: uandispa@gmail.com

Please answer all questions below and press the [SUBMIT] button on all forms.

1. PERSONAL INFORMATION

*Name

*AddressStreet Name, #, City, State, ZIP

*Birthdate

*Phone Number

*Emergency Contact Phone Number

*Relationship

*Email

How did you hear about us?

2. GENERAL INFORMATION ABOUT PROCEDURE

Cold Plasma is a procedure that can only be performed by a specifically trained and qualified specialist technician. Your specialist technician is trained and qualified. Before carrying out the treatment you are required to complete and sign all relevant areas of this consultation record thus giving your absolute consent to treatment. Additionally, you will need to disclose your full medical history as that will determine whether you are a suitable candidate for the proposed
treatment. If the specialist does not think you are suitable for the treatment, then your treatment cannot and will not be carried out. Your specialist will discuss your procedure with you, in full, including what it will involve and the likely benefits. Realistic expectations will be agreed and they will explain any risks, the healing process and will then advise you upon any further treatment you may require if/where necessary. You will then be provided with aftercare information for you and refer to during the subsequent healing process and it is essential you follow these instructions. Any contra-indications will be recorded on this consultation form and
will be used as a reference for any future visits. It is important that you clearly mark any areas of this form that you wish to have clarified or discussed further.
It is ultimately YOUR responsibility to ensure that you understand, in full, the Cold Plasma procedure and the expected outcomes before your treatment commences.
PLEASE READ ALL OF THE FOLLOWING CAREFULLY AND SIGN, WHERE INDICATED, when you are happy to proceed. You must ensure that all the points below have been discussed with your specialist technician. You
are signing to state you understand and accept the terms of your treatment.

3. HEALTH

Have you had in the past or do you currently have:

*Cold Sores/Herpes/Shingles

Yes

*Botox/Fillers within past 21 days

Yes

*Cosmetic Surgery in past year

Yes

*Pregnant/Breast Feeding

Yes

*Cancer

Yes

*Chemotherapy/Radiation

Yes

*Keloids ? Hyperpigmentation ?

Yes

*Cataracts/glaucoma

Yes

*Hemophilia/Blood Disorder

Yes

*Frequent Eye Infections

Yes

*Laser Eye Surgery

Yes

*Rosacea

Yes

*Diabetes

Yes

*Blood thinners

Yes

*Vascular Lesions

Yes

*Drink alcoholic beverages?

Yes

*Do you have any allergies or have you ever experienced allergic reactions? Please let us know

*Do you regularly use Retinol, Glycol, Salicylic Acid or benzoyl peroxide or any other exfoliating products devices?

4. SKIN CARE HISTORY

Please list skin concerns: (wrinkles, acne, rosacea, etc.)

Please list current medications taken, skin care products, brands and routine: (moisturizers, cleansers, serums, masks, etc.)

*Do you use Retinol (Retin-A)?

Yes

What other improvements would you like to see with your skin? (Optional)

5. CLIENT SIGNATURE

I acknowledge that this is an elective procedure at my request.
I certify that I have listed all medications/medical procedures/ medical disorders.
Cold Plasma cannot guarantee the exact outcome of this procedure
and results may vary from client to client.
I grant consent to photographs being taken BEFORE, DURING and AFTER my
Cold Plasma procedure.
I certify I have received written post treatment instructions
I agree to follow all aftercare instructions to reduce the risk of post-procedural
infection, hyperpigmentation, and potential scarring.
I agree to contact U&I Spa Inc with questions or concerns pre or post treatment.
I confi rm I have fully read, understood and completed this Medical Conditions and
Informed Consent Form and that the procedure known as Cold Plasma has been fully explained
to me. I have had the opportunity to ask questions about the treatment and that my questions
have been answered. I understand the importance of fully revealing my accurate and complete
medical history. I understand that withholding any medical information may be detrimental to
my health and safety both during and after my procedure and I confirm that I have not withheld
any medical information. I understand that if there is any change in my medical history it is my
responsibility to inform my technician. I understand that for the desired outcome several treatments may be required and this has been explained to me. I also understand no guarantee has been given as to what the outcome of treatment may or may not be. By my signature I affi rm
that I am at least 18 years old and freely give my informed consent to receiving treatment.

*Client's Signature

*Date

Parent/Guardian Signature Required if client is under 18

Date