Microneedling Consent Form

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NAME *

PHONE NUMBER *

DATE OF BIRTH *

YYYY

STREET ADDRESS, CITY, STATE, ZIP CODE *

I hereby give my consent to undergo Collagen Induction Therapy (Micro-needling) treatments provided by my esthetician. *

I Give My Consent

I understand this technique involves the introduction of fine needles through the skin. The purpose is to create micro-channels in the skin allowing the infusion of active ingredients (such as vitamin C, hyaluronic acid and others) to penetrate deeply and effectively into the dermis, nourishing the skin and stimulating the regrowth of collagen. A series of 4 to 6 treatments are recommended, and the frequency will depend on the intensity and depth of the needle. *

I Understand

I understand that the treatments require many small injections on the area(s) to be treated. I understand that the administration of numbing creams may be used if deemed needed. *

I Understand

I understand that there are some risks with any procedure. The following are possible reactions with Micro needling: temporary bruising, skin discomfort during injections, redness or swelling, lightening or darkening of the skin, itching and burning. Skin infection is a possibility any time an injection or surgical procedure is done. Side effects are most of the time temporary and typically resolve within 3 days. Total healing time depends on the depth of the treatment, skin type, and skin condition, and some patients may heal completely in 24 hours. By my signature, I certify that I have thoroughly read and understood the contents of this form and the disclosures listed above were made to me. I acknowledge that no promises or guarantees have been made to me as a result of the treatment. *

I Understand

I am aware that the results achieved by this treatment may vary from person to person. Some patients typically notice an immediate glow, but visible improvement will take about 2-4 weeks and can continue for up to 6 months. *

I Understand

I have read potential risks have been explained to me, and I accept them. *

I Understand

FULL NAME, USED AS SIGNATURE *

TODAY'S DATE *

YYYY

TIME *

Time

IF UNDER THE AGE OF 18, PARENT/GUARDIAN NAME, USED AS SIGNATURE *

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