Client Name *

Date of Birth *

Phone Number *

Email Address *

Treatment Date *

Practitioner / Witness Name *

Consent Version

Consent Version: ELURENA-CONSENT-PLASMA-GLOW-PRO-V1.0-2026

ELURENA – PLASMA GLOW PRO TREATMENT CONSENT & LIABILITY FORM

About the Treatment Description

Elurena Plasma Glow PRO is a non-surgical skin rejuvenation treatment that uses plasma energy to improve skin texture, reduce fine lines, and stimulate natural healing. Results vary per person and may take several weeks to appear.

What to Expect

During or after Plasma Glow PRO treatment, you may experience:

Warmth, tingling, or mild discomfort during treatment.Temporary redness, swelling, or scabbing may occur in the treated area.Skin may feel tight, sensitive, or dry for a few days.Healing usually occurs within 5–10 days; full results may develop gradually.Rare risks may include burns, pigmentation changes, infection, or scarring.No refunds are offered for treatments.

Do you have open wounds, skin infections, or active acne in the treatment area? *

Yes No

Are you pregnant or breastfeeding? *

Yes No

Do you have a pacemaker or metal implants near the treatment site? *

Yes No

Do you have a history of keloid scarring? *

Yes No

Do you have bleeding disorders or use blood thinners? *

Yes No

Do you have cancer, epilepsy, or uncontrolled diabetes? *

Yes No

Have you recently used retinoids, chemical peels, or laser treatments? *

Yes No

Do you have excessively tanned or sunburned skin? *

Yes No

Have you disclosed your full and accurate medical history to the practitioner? *

Yes No

Are you currently taking any medication that may affect treatment safety? *

Yes No

Have you had any recent cosmetic, medical, or aesthetic procedures in the treatment area? *

Yes No

Do you understand that treatment may be refused or postponed if there is a safety concern? *

Yes No

Plasma Glow PRO Consent Confirmation *

I understand the Plasma Glow PRO treatment, possible risks, contraindications, and limitations. I understand that results are not guaranteed and that multiple sessions may be required. I confirm that I have disclosed my full medical history and give consent to proceed with Plasma Glow PRO treatment.

Optional Photography Consent

I authorize Elurena and its staff to take photographs of me for documenting treatment progress and results, training, education, and marketing use. I understand my name will not be used, my face will not be shown unless I give specific permission, and I may revoke this consent in writing at any time.

Photography Progress Consent

I consent to photographs being taken for treatment progress documentation only.

Photography Training Consent

I consent to photographs being used for training and education.

Photography Marketing Consent

I consent to photographs being used for marketing, digital, print, or online purposes.

Photography Face Consent

I specifically consent to my face being shown, if required.

Treatment Information Confirmation *

I confirm that I have read and understood the Plasma Glow PRO treatment information shown in this form.

Risks and Limitations Confirmation *

I confirm that I understand the possible risks, side effects, contraindications, and limitations of Plasma Glow PRO treatment.

No Guaranteed Results Confirmation *

I understand that treatment results vary and are not guaranteed.

Multiple Sessions Confirmation *

I understand that more than one session may be required.

No Refunds Confirmation *

I understand that no refunds are offered for completed treatments.

Questions Confirmation *

I confirm that I have had the opportunity to ask questions before proceeding.

Consent to Proceed *

I consent to proceed with Plasma Glow PRO treatment.

Client Signature *

Client Signature Date *

Practitioner / Witness Signature *

Practitioner / Witness Signature Date *

ELURENA – Plasma Glow PRO Treatment Consent Form

ELURENA – PLASMA GLOW PRO TREATMENT CONSENT & LIABILITY FORM