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.

MICRONEEDLING CONSENT FORM

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