The First Step

Consent Form

We are excited to begin your treatment. Please fill out the information below before being treated.

Fill Out the Form Below to Provide Consent

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INTRODUCTION

Neogen® PSR (Plasma Skin Regeneration) is a skin rejuvenation procedure that utilizes nitrogen plasma energy to deliver controlled thermal energy to the skin. This process stimulates collagen remodeling, skin regeneration, tissue tightening, and improvement in the appearance of aging, sun damage, uneven skin texture, scars, and skin laxity.

Neogen PSR may be performed on the face, neck, chest, hands, and other areas as determined appropriate by your provider.

I understand that Neogen PSR is an elective cosmetic procedure and that individual results vary.

TREATMENT BENEFITS

Potential benefits may include:

Improvement in fine lines and wrinkles
Improvement in skin texture
Reduction in sun damage
Improvement in skin laxity
Improvement in acne scars
Improvement in surgical scars
Improved skin tone and pigmentation
Stimulation of collagen production
Skin tightening
General skin rejuvenation

I understand that multiple treatments may be recommended to achieve optimal results.

I understand that no guarantee of results has been made.

PRE-TREATMENT ACKNOWLEDGMENT*

PRE-TREATMENT ACKNOWLEDGMENT

I acknowledge that I have received and reviewed all pre-treatment instructions. I certify that:

have not used topical steroids in the treatment area within the previous two (2) weeks.

I do not currently have an active infection.

I am not currently ill with fever, flu-like symptoms, or other contagious illness.

I have disclosed all medications and supplements to my provider.

I have followed all pre-treatment instructions.

I understand the importance of hydration before treatment.

I understand the recommendation to consume 1–2 electrolyte beverages daily for one week before and after treatment.

CONTRAINDICATION SCREENING

Please check any condition that applies:

Pregnancy and Breastfeeding*

Pregnant

Attempting pregnancy

Breastfeeding

Cardiac/Electrical Devices*

Pacemaker

Implantable cardioverter-defibrillator (ICD)

Internal electrical device

Neurostimulator

Medical Conditions*

Active cancer

Active skin cancer in treatment area

Uncontrolled diabetes

Autoimmune disease flare

Immunocompromised condition

Connective tissue disorder

Poor wound healing

History of radiation to treatment area

Skin Conditions*

Active infection

Open wound

Active cold sore (HSV)

Active acne cyst or infection

Active rash

Sunburn

Suspicious lesion

Medications*

Chemotherapy

Radiation therapy

Immunomodulating medications

Oral corticosteroids

Topical corticosteroids within previous two weeks

Isotretinoin (Accutane) within previous six months

Blood thinners

Scarring History*

History of keloids

History of hypertrophic scars

History of abnormal wound healing

None of the above

PROCEDURE EXPECTATIONS

I understand that after treatment I may experience:

Redness
Swelling
Tightness
Warmth
Crusting
Peeling
Flaking
Bronzing of the skin
Temporary discomfort

I understand that recovery time varies depending on treatment intensity.

I understand visible healing may take several days to several weeks.

I understand collagen remodeling and continued improvement may occur over several months following treatment.

RISKS AND COMPLICATIONS

I understand all medical and aesthetic procedures carry risks. Potential complications include:

Redness
Swelling
Bruising
Itching
Dryness
Crusting
Delayed healing
Infection
Acne flare
Milia formation
Hyperpigmentation
Hypopigmentation
Prolonged erythema
Scarring
Unsatisfactory cosmetic outcome
Need for additional treatment

Although uncommon, permanent pigment changes and scarring are possible.

HERPES SIMPLEX (COLD SORE) DISCLOSURE

If I have a history of oral herpes (cold sores), I understand that Neogen PSR may trigger a recurrence.

I agree to inform my provider of any history of herpes simplex infection.

I understand antiviral prophylaxis may be recommended.

SUN EXPOSURE ACKNOWLEDGMENT

I understand that:

Sun exposure before or after treatment may increase complications.
Strict sun protection is required during healing.
Hyperpigmentation risk increases with inadequate sun protection.
Daily broad-spectrum SPF 30+ or higher is recommended.

PHOTOGRAPHY AUTHORIZATION*

Clinical photographs may be taken before, during, and after treatment for medical documentation. Please select one:

Medical record documentation only

Medical records and de-identified educational/marketing use

Decline marketing use

SUN EXPOSURE ACKNOWLEDGMENT

I understand:

Results vary between individuals.
Multiple treatments may be necessary.
Maintenance treatments may be recommended.
Aging and environmental damage continue despite treatment.
No guarantees or warranties have been made regarding my results.

FINANCIAL RESPONSIBILITY

I understand Neogen PSR is an elective cosmetic procedure and is generally not covered by insurance.

I accept responsibility for all treatment-related fees.

RELEASE OF LIABILITY

I understand that medicine and aesthetics are not exact sciences.

I understand no guarantee or warranty has been made regarding treatment outcomes.

I voluntarily consent to Neogen PSR treatment and accept the known and unknown risks associated with the procedure.

I release and hold harmless Emergent Medtech, providers, employees, contractors, and affiliates from liability arising from known or unforeseen complications except in cases of gross negligence or willful misconduct as permitted under Ohio law.

PATIENT CERTIFICATION

I certify that:

I have read and understand this consent form.
I have disclosed all relevant medical history.
I have had the opportunity to ask questions.
My questions have been answered to my satisfaction.
I voluntarily consent to treatment.

Signature*

Date

MM slash DD slash YYYY

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