Microneedling Wavier Form

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Absolute Contraindications: Scleroderma, collagen vascular disease, or cardiac abnormalities, rosacea, blood clotting problems, platelet abnormalities, anticoagulation therapy (i.e.: Warfarin), facial cancer, past and present, chemotherapy, steroid therapy, dermatological diseases affecting the face (i.e. Porphyria), diabetes and other chronic conditions, active bacterial or fungal infections, immune-suppression, scars less than 6 months old and facial fillers in the past 2-4 weeks. Treatment is not recommended for patients who are pregnant or nursing.

Precautions: keloid or raised scarring, eczema, psoriasis, actinic keratosis, and herpes simplex.

Side Effects Typically Include:

Skin will be pink or red and may feel warm, like mild sunburn, tight and itchy, which usually subside in 12 to 24 hrs.
Minor flaking or dryness of the skin, with scab formation in rare cases.
Crusting, discomfort, bruising and swelling may occur.
Pinpoint bleeding.
It is possible to have a cold sore flare if you have a history of outbreaks.
Freckles may lighten temporarily or permanently disappear in treated areas.
Infection is rare but if you see any signs of tender redness or puss notify our office immediately.
Hyperpigmentation (darkening of the skin) rarely occurs and usually resolves itself after a month.
Permanent scarring (less than 1%) is extremely rare.

I understand, read and completed the questionnaire truthfully. I understand that withholding ANY information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I understand that this waiver replaces any verbal or written disclosures. The treatments I receive here are voluntary, and I release Ashley Lynn Esthetics and/or esthetician from any liability, and I assure full responsibility thereof. I hereby grant irrevocable consent to and authorize the use of any reproduction by Ashley Lynn Esthetics, all photographs which are taken of me, negative or positive proof which will be hereby attached for any purposes whatsoever, without further compensation to me. All negatives, together with the prints, video or live internet stream shall become and remain the property of Ashley Lynn Esthetics, solely and completely. I understand and release Ashley Spina from any liability if I should fall or hurt myself in any way on her property located at 641 Union Rd. I understand that Ashley Spina is not responsible for lost, stolen or damaged items including my vehicle that is parked on the property.*

Date*

Date