SKINPEN MICRONEEDLING FORM

Please fill out and submit the Consultation Form below which enables us to treat you.

* - Required Field.

First Name*
Last Name*
Are you 18 or over?*
Date of Birth*
Phone*
Email Address*
Address*
Postcode*
CONSENT FOR SKIN PEN MICRONEEDLING

I am aware that the treatment is carried out by micro needles for the improvement of the skin.
I consent to receiving the treatment.
I understand the importance of withholding any medical conditions may be detrimental to my health and the outcome of the procedure.
I confirm that it is my responsibility to ask sufficient information about the treatment and products used.
I understand multiple treatments may be necessary, treatment results are varied and not guaranteed.
I have discussed my expectations and goals with my practitioner: *
POSSIBLE SIDE EFFECTS

Due to the use of micro needles, I understand that the following contra-actions may occur: • Bruising • Itching/irritation • Infection • Histamine reaction • Localised allergic reaction • Urticaria • Discomfort.
Pre Treatment advice and After Care: I am over 18years old. I am not pregnant or lactating. I do not have any active Herpes simplex (cold sores). Prophylactic antiviral medication or topical antiviral cream may be used up to 5 days before treatment and up to 5 days after treatment.
I agree not to receive any of the following on the treatment area 2-4 week prior to treatment – Botox, injectable dermal filers or needling treatments.
I agree not to receive any of the following on the treatment area 1-2 weeks prior to treatment – bleaching, electrolysis, depilation, facial treatments using AHA/BHA/Vitamin A, hair colouring, IPL/Laser for skin rejuvenation, IPL/Laser for hair removal, light therapy, microdermabrasion.
I agree to avoid the use of any prescribed topical medications i.e. Retin A, Salicylic Acid a minimum of 2 weeks prior to treatment.
I agree to avoid the use of active skin care 3-5 days prior to treatment.
I confirm that I have not used Isotretinoin in the past 6 months.
I agree to follow the treatment protocol advised by my practitioner for a minimum of 2 weeks prior to treatment.
I agree to avoid direct sun exposure.
I agree to apply a sunscreen daily (minimum SPF30).
I agree to avoid heat treatment immediately prior to treatment.
I agree to notify my practitioner of any concerns: *
PRECAUTIONS & CONTRAINDICATIONS

Active acne, Allergy to surgical grade stainless steel, Anticoagulant/steroid medication, Blood borne diseases Contagious skin diseases, Hypersensitive skin, Haemophilia, Inflammation swelling, Isotretinoin use in the last 6 months, Open wound(s), Photosensitising medication, Recent scar tissue, Rosacea, Skin Cancer, Undiagnosed lumps Immunosuppressive therapy (MS,Lupus, RA), Cardiac abnormalities, collagen vascular diseases / scleroderma.
Post treatment: Do Not touch the treated area (infection).
Use the remaining HG lift that will be given to you and the day after treatment use the Rescue or Hydrating product.
Avoid exercise, saunas, steam rooms etc. excess heat can lead to discomfort, inflammation, irritation etc 5days.
Avoid exfoliating products, waxing/shaving hair removal treatments 2weeks. Avoid using skincare containing AHAs, BHAs and retinoids for 48 hours.
Do not pick or peel loose skin that may begin to flake following treatment. Do not have any other clinical treatments 4 weeks post treatment.
Keep out of the sun on the day of treatment and for the following 24 hours. Use sunscreen factor 50 and keep out of direct sunlight to maximise long term results.
Increase water intake to at least 8 glasses per day: *
ACKNOWLEDGMENT

I understand and acknowledge that payments for the above procedure are non-refundable and due at the time of service.
I further agree in the event of non-payment, to bear the cost of collection and/or Court cost and reasonable legal fees should this be required.
I understand the need for topical anaesthetic may be necessary to reduce the discomfort of the procedure and consent to the application.
I certify that I have read and fully understand the content of this consent form for the procedure and that the disclosures referred to herein were made to me.
I am not pregnant and I am not breastfeeding, I am over 18years old.
I understand and consent to photos for before and after comparisons.
I agree to follow all post treatment instructions carefully and understand that these guidelines are crucial for healing, prevention of side effects and complications.
I have been informed of the risks and benefits of this treatment and wish to proceed with the treatment.
I hereby give consent to carry out the treatment of my choice.
I hereby release the practitioner and the facility from liability associated with this procedure and all future procedures.
I hereby authorise Dolly Patel to administer such treatment to me and agree to hold her free from any claims, suits or damages for any injury or complications resulting from this treatment.
I confirm that I accept all liability: *
Sign Your Name*
Date*