top of page
Facial Treatment

Dr. Platon Cold Plasma Consent

Dr Platon Cold Plasma Therapy offers a non-invasive, pain-free solution to various skin concerns, including acne, inflammation, and signs of aging. Utilising advanced Plasma Shower technology, this treatment delivers cold (non-thermal) atmospheric plasma to the skin, promoting healing and rejuvenation without downtime.

​

How Does Dr Platon Cold Plasma Work?

Dr Platon employs Plasma Shower technology to convert atmospheric gases—primarily oxygen and nitrogen—into cold plasma. When applied to the skin, this plasma:

​

  • Destroys acne-causing bacteria (P. acnes)

  • Reduces inflammation and soothes irritated skin

  • Balances sebum production to prevent future breakouts

  • Stimulates collagen production for improved skin elasticity

  • Enhances absorption of skincare products by up to 24%
     

The treatment is gentle, making it suitable for all skin types, including sensitive skin.

making it a highly effective tool for treating:

​

  • Teen and adult acne

  • Rosacea

  • Seborrhoea

  • Psoriasis

  • Eczema

  • Atopic dermatitis

Disclaimer:

Please ensure that all consent forms are relevant to you as a practitioner and verified by your insurance company.


It is your responsibility to ensure your consent form is correct.


Prior to receiving treatment, please reveal any conditions that may have an effect on this treatment. If you are unsure of any details including personal requirements and potential complications, please discuss with your practitioner.

Are you currently under a doctor’s or specialist’s care?
Yes
No
Do you take any over-the-counter or prescription medication or herbal/natural remedies on a regular basis?
Yes
No
Do you have any current chronic or serious medical illnesses such as diabetes, heart disease/angina, epilepsy, hepatitis, blood disorders, cancer?
Yes
No
Do you have any autoimmune diseases such as psoriasis, lupus, rheumatoid arthiritus, or any condition that may weaken your immune system.
Yes
No
Do you have or have had any form of skin cancer?
Yes
No
Are you currently receiving chemotherapy or radiotherapy?
Yes
No
Have you taken medication for acne such as oral retinoids (Roaccutane) or benzoyl peroxide in the last 6 months?
Yes
No
Have you taken medication for acne such as oral retinoids (Roaccutane) or benzoyl peroxide in the last 6 months?
Yes
No
Are you currently taking steroids or anti-coagulants on a daily basis?
Yes
No
Do you have a predisposition to keloid or hypertrophic scars?
Yes
No
Have you used any products containing topical retinoids (Vitamin A, Retinol, Retin A etc) in the last week?
Yes
No
Have you used any exfoliants or products containing alpha hydroxy (AHAs), beta hydroxy (BHAs) acids (such glycolic acid, lactic acid, fruit acids) or hydroquinone in the last week?
Yes
No
Have you had any recent operations, facial surgery or aesthetic treatments?
Yes
No
Have you had electrolysis, depilatory creams, or waxing on the area to be treated in the last week?
Yes
No
Have you had any recent sunburn, windburn, cuts or skin abrasions?
Yes
No
Do you use sunbeds or have regular sun exposure?
Yes
No
Do you smoke?
Yes
No

For women:

Are you pregnant or is there any possibility that you are pregnant?
Yes
No
Not applicable
Are you breastfeeding?
Yes
No
Not applicable
Are there any other aspects of your health that have not been identified above and we should be made aware of?
Yes
No
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
Day
Month
Year

I confirm that I understands the risks and conditions associated with Plasma Shower treatment and that it is an elective procedure.


Dr Platon is a safe, non-invasive and effective treatment. It employs the aesthetic technology of cold atmospheric plasma.


It transforms the air between its tip and the patient’s skin (mainly Oxygen and Nitrogen) into a plasma state - highly charged gas, with unbound ions and free electrons. This plasma is highly beneficial to the skin, yet is safe to the touch (temperature of 38-40 ⁰C) and causes no skin ablation. Therefore, patients do not require any downtime post-treatment.


Treatment by the Dr Platon cold atmospheric plasma is highly effective in:


  • Acne treatment - It destroys P. acne bacteria and balances sebum production.


  • Reducing skin inflammation and blemishes


  • Soothing irritated, dehydrated, and itchy skin, in cases of chronic skin diseases, such as atopic dermatitis, eczema, psoriasis, or seborrhoea.


  • Brightening the skin and reducing hyperpigmentation.


  • Improving absorption of active ingredients by the skin, thus increasing the impact of active ingredients.


  • Rejuvenating the skin - Triggering division of the basal cells and production of new collagen, strengthening the skin immune system and the epidermal barrier.


Contraindications


I understand that there are certain contraindications/precautions that would preclude me from receiving treatment including:


  • An electronic device (e.g., a pacemaker, cochlear implant) is permanently attached to the patient’s body


  • The patient’s body is attached to life-support electronic devices or to any installation-type electronic devices (e.g., electrocardiograph)


  • Patients who are pregnant or breastfeeding


  • The patient suffers from Epilepsy (especially dangerous)


  • The patient suffers from an unstable heart condition


  • The patient suffers from unstable, insulin-dependent diabetes


  • The patient suffers from Hemophilia


  • The patient has a history of blood coagulation disorders (except Thrombophilia)


  • The patient suffers from Hepatitis


  • The patient suffers from AIDS, which is manifested in open skin lesions


  • The patient suffers from ALS (Amyotrophic lateral sclerosis or Lou Gehrig’s disease)


  • The patient suffers from autoimmune disorders, such as Fibromyalgia, Lupus, or Vitiligo


  • The patient has cancer, or is in remission from cancer for less than 5 years


  • The patient suffers from any immunodeficiency


  • The patient suffers from unstable hypertension (high blood pressure)


  • The patient suffers from an active chronic disease


  • The patient’s body temperature is over 38º or the patient feels sick


  • The patient suffers from Herpes (either active or still healing)


  • The patients is taking steroids, or has taken steroids within the past 2 weeks


  • The patient has used AHAs or Retinol in the past week


  • The patient has had a face lift by injecting permanent or dissolvable threads to the dermis in the past month


Please note: Injections of Botox, silicone or hyaluronic acid dermal fillers to the face, even in the past several days, are not a contraindication for treatment by Dr Platon.


Possible risks and complications


Dr Platon is a safe treatment. Cold plasma may temporarily increase the photosensitivity of skin. Plasma also temporarily increases epidermal permeability, failure to follow aftercare advice and using unsuitable products post treatment (containing for example AHA or Retinol), may cause reactions.


Post treatment advice


  • Following your Plasma Shower treatment, your skin will continue to absorb anything that is applied after the treatment for up to 12 hours. It is therefore VERY important that nothing is applied to the skin for 12 hours unless approved by your practitioner.


  • Cold plasma may temporarily increase the photosensitivity of skin so daily application of a gentle sunscreen with a minimum of 30 SPF is highly recommended after each treatment and during the treatment course.


  • DO NOT apply any solution containing alcohol to the area. Clean as necessary using water. If soap is needed use


  • only non-perfumed, non-colored soap, for example, CLINICCARE Concentrated Cleansing Foam.

  • DO NOT apply any type of AHA, Retionol or exfoliation products for at least 12 hours post treatment as this can irritate the skin.


  • No makeup can be worn after the treatment for 12 hours.


  • DO NOT participate in activities that may cause excessive sweating for 12 hours after treatment.


  • Refrain from extreme temperatures such as intensive sun light, saunas, sunbeds and steam baths for 12 hours


  • Avoid electrolysis, waxing, bleaching (face), depilatory creams, laser hair removal for at least 72 hours.


  • Do not swim in chlorinated water for 12 hours.


  • Please report any concerns to your practitioner as soon as possible.


  • Schedule a follow up treatment with your practitioner.


Consent to treatment


I confirm that the medical history and medication details that I have supplied are complete and correct and that there is no other medical information I need to disclose.


I understand that withholding any medical information may be detrimental to my health and safety during the treatment in which I agree to undertake.


If there is any change in my medical history, it is my responsibility to advise the practitioner before further treatments are carried out.


I understand that there are certain contraindications that would preclude me from receiving treatment.


I confirm that I understand the risks and conditions associated with the treatment. These have been fully explained to me and I have had the opportunity to ask any questions and these have been answered to my satisfaction.


Development of any reactions must be reported to the practitioner as soon as possible.


I accept and understand that there are no written, implied, or verbal guarantees as to the anticipated results of this treatment and that the effects of treatment will vary with some patients than with others and that the goal of this treatment is improvement, not perfection.


I may require a series of treatments, normally 1 week between procedures, to achieve the maximum cosmetic result.


I have been given post treatment advice and I understand and agree to follow all the care instructions carefully to minimise the risk of side effects.


I confirm that I understand that this is an elective treatment and that I have been allowed sufficient time to make a carefully considered decision.


I consent to the taking of (pre and post-treatment) photographs to monitor treatment effects.


Complete patient confidentiality will be maintained at all times.

I also consent to photographs being used for Saviour Skin Spa Social Media.
I also consent to photographs being used for Educational purposes.
I also consent to photographs being used for Saviour Skin Spa Website.
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
bottom of page