Plasma Pre-Booking Questionnaire

Please answer all the questions to ensure your safety and best treatment outcomes

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Your Name (required)

First

Last

Email (required)

Mobile Number (required)

Please select your reason for plasma treatment (dropdown) (required)Skin TighteningLesion Removal

Are you over 18 years old (required)

• Yes
• No

Are you pregnant or breastfeeding? (required)

• Yes
• No

Have you ever experienced keloid or hypertrophic (thick, raised) scarring? (required)

• Yes
• No

Have you used a retinol or other active skincare product in the past 4 weeks? (required)

• Yes
• No

Do you have any dyschromia conditions such as melasma or vitiligo? (required)

• Yes
• No

Do you suffer with skin-picking disorders? (required)

• Yes
• No

Have you had skin tightening treatment previously? (required)

• Yes
• No

Have you been diagnosed with high blood pressure? (required)

• Yes
• No

Do you take any medication which thins your blood (anti-coagulants)? (required)

• Yes
• No

Have you been treated for active cancer anywhere in the body in the last 12 months? (required)

• Yes
• No

Do you have any allergies? (required)

• Yes
• No

Do you have diabetes – Type 1 or Type 2? (required)

• Yes
• No

Do you currently take any medication? (required)

• Yes
• No

Do you suffer with any medical conditions not mentioned above? (required)

• Yes
• No

If you have answered 'Yes' to anyof the above question please give details below (dates, medication etc)

How would you describe your skin-type? (required)

• Fitzpatrick Type I – Ivory, always freckles, never tans, always burns/peels
• Fitzpatrick Type II – Fair/Pale- usually freckles, often burns/peels, rarely tans
• Fitzpatrick Type III – Fair to beige with golden undertones – might freckle, sometimes burns, sometimes tans
• Fitzpatrick Type IV – Olive to light brown- doesn’t freckle, rarely burns, often tans
• Fitzpatrick Type V – Dark brown – rarely freckles, almost never burns, always tans
• Fitzpatrick Type VI – Deeply pigmented, dark brown to darkest brown, never freckles, never burns, always tans

Select one option

PLEASE NOTE: You will not be able to wear contact lenses, false eyelashes or any eye make-up if treatment is around the eye area either to the treatment appointment and for at least one week afterwards (until the carbon dots come off). You cannot have plasma treatment if you have a tan, either natural or via a sunbed. You will not be able to go on sunbeds or expose the treated area to direct sunshine for 12 weeks. SPF factor 50 MUST be worn at all times regardless of the weather conditions if you are outside. You will have small carbon spots on the surface of the treated area following your treatment which must be left alone to heal and drop off naturally. If you pick or rub them off prematurely, or wear make-up/use other products you may increase the risk of infection & scarring. Please acknowledge that you have read and agree to these conditions in the box below.

Please confirm that you have read and understood the treatment profile on LHP Website link- https://www.lhpaesthetics.com/treatments/fibroblast-plasma-pen/ (required)

• Yes, I have read and understood the treatment information including pre and post care advice

Please confirm that you understand that you will not be able to expose the treated area to the sun or a sun bed for a minimum of 12 weeks & must wear SPF50 whilst outside for this time (we recommend daily SPF regardless) (required)

• Yes, I am aware and agree to the above

Please confirm that you have answered this questionnaire truthfully, to the best of your knowledge, and not withheld any relevant information (required)

• Yes, I confirm the above

Signature (required)

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Date (required)

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