MICRONEEDLING CONSENT FORM

Microneedling Conset: Prior to receiving this treatment, I have been candid in revealing any condition that may have a
bearing on this procedure, such as: pregnancy, recent facial peels or surgery, allergies, tendencies to
cold sores and fever blisters, Use of Retin-A, Glycolic Acids, Accutane, Hormonal Therapy Anticoagulants
and Aspirin.

I understand there are no guarantees to this procedure.
I understand there may be some degree of minor discomfort (scratchiness, itchiness and bruising).
I understand that to achieve maximum results, I will need several ongoing treatments and will need to use daily products to heal and protect my skin.
I understand that the possibility of irritation and redness exists and that I should notify my skin care professional if irritation persists.
I will follow the home care program specifically designed for me without changing or adding any products without consulting with my skin care professional.
I agree to all of the above to have this treatment performed on me and will follow all prescribed directions regarding post treatment care.

Date:

Signature:

MICRONEEDLING CONSENT FORM

I understand there are no guarantees to this procedure.
I understand there may be some degree of minor discomfort (scratchiness, itchiness and bruising).
I understand that to achieve maximum results, I will need several ongoing treatments and will need to use daily products to heal and protect my skin.
I understand that the possibility of irritation and redness exists and that I should notify my skin care professional if irritation persists.
I will follow the home care program specifically designed for me without changing or adding any products without consulting with my skin care professional.
I agree to all of the above to have this treatment performed on me and will follow all prescribed directions regarding post treatment care.

MICRONEEDLING CONSENT FORM

MICRONEEDLING CONSENT FORM

PRINT NAME:

SIGNATURE:

DATE:

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