Micro Needling Consent Form – Celebrity Skin Studio

Today's Date*

Name*

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Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

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Date of Birth*

Current Age*

Please enter a number from 1 to 100.

How did you hear about us? Is there anyone we can thank for your referral?*

Please be as specific as possible so we know what's working. Ask about referral rewards!

Please describe any areas of concern you would like to focus on.*

Indicate location and type of concerns you have. For example: right cheek pigmentation.

Micro needling allows for controlled induction of the skin’s self-repair mechanism by creating micro “injuries” in the skin which triggers new collagen synthesis. The result is smoother, firmer and younger looking skin. Skin needling procedures are performed in a safe and precise manner with the use of the sterile, single use micro pen needle head. The procedure is normally completed within 30-60 minutes depending on the required treatment and anatomical site. After the procedure, the skin will be red and flushed in appearance in a similar way to moderate sunburn. You may have pin point bleeding in some areas. You may also experience skin tightness and mild sensitivity to touch on the area being treated. The skin’s redness will diminish greatly after a few hours following the treatment and within the next 24 hours the skin will be generally calmed. After 3 days the skin will return to a normal or near normal appearance.

Please check if you have any of the following conditions*

Check all that apply, if none, click none of the above

Do You Smoke?*

Yes
No

Are You Pregnant or Breast Feeding?*

Yes
No

Are you currently taking Aspirin or Ibuprofen?*

Yes
No

Are you on any blood thinning medication?*

Yes
No

Are you allergic or sensitive to Lidocaine numbing products?*

Yes
No

LIst any vitamins or suppliments you take. If none list N/A*

Have you had any recent Skin Care or Cosmetic procedures in the last 2 months?

List any medical or cosmetic procedures and the date received such as injections, resurfacing treatments/laser or chemical peels, surgeries etc. It is important to keep your technician updated on any procedures received.

Please Read and check the box below*

I understand that results will vary between individuals.

I understand that although I may see a change after my first
treatment; I may require a series of sessions to obtain my desired outcome.

I am advised that good results are expected, the possibility and nature of complications cannot be accurately
anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of
the treatment.

I am aware that the micro needling treatment is not permanent as natural degradation will occur over time.
I have made Celebrity Skin Studio aware of any possible contraindications that may pertain to me.

I understand that to acheive the best results I should follow the home care recommendations of my esthetician.

I understand and agree to the above

BEFORE your treatment: Discontinue use of Alpha Hydroxy Acids, Beta Hydroxy Acids, Retin A, Retinols, Vitamin A creams and other topical medications as well as Vitamin C (in a low pH formula) or anything perceived as ‘active’ skincare for 3-5 days before your micro needling treatment. In addition, avoid avoid fish oil or any anti-inflammatory tablets, or aspirin 3-5 days before as well as this increases your risk of bleeding. Do not apply any serums or products after cleansing your skin the day of your appointment. Avoid Sun and Wind exposure several days before your appointment as compromised skin can not be treated. If you have an active coldsore or skin infection you will need to reschedule. If you have an issue with coldsores, you may want to talk to your Dr. about Pre-medicating.

AFTER your treatment: Bring something to keep your hair off your face. Do not wash your face the day of your treatment. Let the applied products penetrate into your skin. Wait until the following day to cleanse and use a gentle cleanser and room temperature water, continue this process AM and PM until any irritation from treatment is gone. I recommend using the Celebrity Skin-Face & Neck Repair Kit after your treamtent. This kit should last about 2 weeks. Do not use any Alpha Hydroxy Acids, Beta Hydroxy Acid, Retinol (Vitamin A), Vitamin C (in a low pH formula) or anything perceived as ‘active’ skincare for at least 7 days post-treatment. Keep hair off of face and refrain from touching the treated area. Avoid intentional and direct sunlight, and wear SPF. No tanning beds. Do not go swimming for 3 to 4 days post-treatment. AVOID excessive exercise, sauna, beach, excess sweating for at least 3 to 4 days. Sweating and gym environments are harmful, ripe with bacteria, and may cause adverse reactions. Men can resume shaving after 2 days as long as therre is no sensitivy or peeling. Use sunscreen and follow your recommended home care regimen.

Consent*

I understand the pre and post treatment instructions and agree to follow the directions and recommendations of my esthetician.

Consent for Treatment and Liablity Waiver*

I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform treatments/procedures and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today I agree to update my service provider of any changes to this form. I understand photos may be taken for documentation purposes and may be used in promotional materials and social media posts.

By checking the box and signature below, I agree to Consent for Treatment and Liability Waiver

Signature*

Date*

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