Microneedling / Collagen Induction Therapy Informed Consent               

I understand there is no guarantee that can be given to me as to the condition of my skin or degree of improvement expected in the following treatment, that multiple treatments and the use of the recommended home skin care maintenance are required to achieve optimal results. I am not pregnant or lactating and I have told the medical staff about any allergies. 

You are eligible for micro-needling if the following applies to you: 

• Lack of skin radiance, loss of elasticity and epidermal thickness, rough and uneven skin texture 
• Fine lines, Wrinkles, Crow’s feet 
• Hyperpigmentation, melasma Scars, especially indented acne or chicken pox. Post surgical Scars 
• Skin Dullness, Dry Skin   

 You are NOT eligible for micro-needling if the following applies to you: 

• This treatment should not be used on patients with active skin cancer or active bacterial, fungal or viral (i.e. herpes, warts) skin infections in the procedure area(s). NOTE: This product
  is not intended for transdermal (under the skin) delivery of cosmetics.
• You suffer with active pustular acne, Active bacterial, viral or fungal infections 
• Eczema, Psoriasis, Rosacea, Actinic (solar) keratosis or Diabetes
• Keloid or raised scars or scars less than 6 months old, presently using isotretinoin (Accutane)
• Raised moles or warts, had facial surgery in the past 6 months 
• Patients taking blood pressure, blood thinning or heart medications or Immunosuppression

Side Effects

After the micro-needling procedure, you may experience redness and flushing on the treated area, similar to a moderate sunburn. You may also feel some skin tightness and mild sensitivity to touch. However, these symptoms will diminish greatly within a few hours of treatment, and the skin should be fully healed within 24 hours.

Please note that results may vary among individuals, and a series of sessions may be necessary to achieve your desired outcome. While good results are expected, it is impossible to predict the possibility and nature of complications, and there can be no guarantee, expressed or implied, as to the success or other results of the treatment. It is also important to understand that micro-needling is not a permanent solution, as natural degradation will occur over time.

By signing below, I confirm that I have read and fully understand the information presented in this consent form. I give permission to my skin therapist, Allana Davis Studio (operated by MakeupLady Canada), to perform the micro-needling procedure we have discussed and release her, the medical director, and staff from any liability that may result from this treatment. I acknowledge that my therapist will take every precaution to minimize or eliminate negative reactions, such as blisters, sores, or other reactions, as much as possible.

I confirm that I have provided an accurate account of any over-the-counter or prescription medications that I use regularly and have disclosed any other over-the-counter product or prescription medication that I am ingesting or using topically. I also confirm that I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn, or broken skin, and I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. Additionally, I confirm that I do not have a history of keloid scarring, excessive telangiectasia, viral infections, open lesions or rashes, active acne, any autoimmune disease, or any other existing condition that may interfere with the positive outcome of this treatment.

By signing below, I acknowledge and consent to the following statements:

I acknowledge that temporary skin irritation, breakout, tightness, redness, or slight swelling may occur after the treatment, which usually dissipates within 72 hours depending on my skin sensitivity.

I acknowledge that if I have any allergies to the products used, I may experience allergic reactions.

I acknowledge that failure to use a minimal SPF 30 sunscreen may result in sunburn, skin damage, and hyperpigmentation, and I should avoid excessive sun exposure, especially between 10am-2pm.

I acknowledge that this treatment is strictly an elective cosmetic procedure, and no medical claims have been expressed or implied.

I acknowledge that I should avoid using Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following the treatment unless discussed with my aesthetician at Allana Davis Studio (operated by MakeupLady Canada).

I acknowledge that I have informed my esthetician of any medical conditions, allergies, or medications that could increase the risk of complications during or after the treatment.

I acknowledge that I have been provided with a detailed description of the facial/microneedling procedure that will be performed, including the equipment and products that will be used, the length of the treatment, and any post-treatment instructions.

I acknowledge that there are risks associated with this facial/microneedling treatment, and I assume all responsibility for any complications that may arise. I release Allana Davis Studio (operated by MakeupLady Canada) and its staff from any liability, claims, damages, or expenses that may result from the treatment.

I give consent to the best of my knowledge that the answers I have provided are correct and that I have not withheld any relevant information for my treatment. I also give consent for all future treatments.

I acknowledge that [your business name] carries insurance coverage for this facial/microneedling treatment and that this consent form meets the insurance provider's requirements.

Cancellation Policy:

At the Allana Davis Studio (operated by MakeupLady Canada), we highly value your appointments and consider them a top priority. We reserve your appointment slot exclusively for you and understand that schedule changes may become necessary. We kindly ask that you provide us with a minimum of 24 hours' notice for any cancellations.

For appointments cancelled less than 24 hours in advance, a charge equivalent to 100% of the original appointment cost will be applied to your credit card on file or billed at your next appointment. For same-day cancellations, the full cost of the original appointment will be charged to your credit card on file or billed at your next appointment. We appreciate your understanding and cooperation.

I have read and understood the information provided in this consent form, and I agree to the terms and conditions.