Micro-Needling Consent Form

Micro-Needling Consent Form

Thank you for Choosing EN Signature Brows and Beauty Studio for your services. We love to give our clients the best quality service. Please fill out the form below.
Name *

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Micro-needling is based on the skin’s natural ability to repair itself. Micro-needling treatments create superficial “micro-channels” to the outermost layer of the skin, inducing the healing process including new collagen production. Micro-needling has been shown to reduce the visibility of acne scars, fine lines, and wrinkles, diminish hyperpigmentation, and improve skin tone and texture.
I hereby authorize and direct the associates or assistants of Elizaveta Neginskaya LLC. to perform my Micro-needling treatments. *
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I understand possible side effects include and are not limited to: slight or extreme redness, histamine reaction, swelling, stinging, itchy, tender, dry or flaking skin. In rare instances, hyperpigmentation/hypopigmentation, scarring, or infection can occur. I UNDERSTAND THAT I SHOULD ONLY APPLY PRODUCTS RECOMMEDED BY MY AESTHETICIANPOST TREATMENT. *
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Improvement of the skin may also be accomplished by other treatments. Options include laser skin surface treatments, chemical peels, microdermabrasion, and facials. Other options not mentioned here may exist. Risk and potential complications are associated with alternative treatments. *
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Most side effects will gradually diminish over time as healing may take several days. Notify your Aesthetician if any side effects cause extreme discomfort or any unexpected problems occur immediately.
I have avoided the following products/procedures THREE DAYS prior to treatment: *

Topical prescriptions including but not limited to Retin-A, Tretinoin, Differin, Tazorac Abrasive scrubs or other exfoliating products
I have not had any cosmetic injections within the last TWO WEEKS. *
Notify your technician PRIOR TO SIGNING THIS CONSENT if any of the following apply to you: *

Cold sores(or history), warts, open skin lesions, sunburn, extreme sensitivity, dermatitis, rosacea Blood thinning medications Accutane or generic within the past year Pregnant or breastfeeding Received chemotherapy or radiation therapy Collagen Vascular Disease Eczema, Psoriasis, or Dermatitis Hemophilia / bleeding disorders Keloid/hypertrophic scaring History of autoimmune disease or any condition that may weaken you immune system
I am undergoing treatment of my own free will. I agree that this procedure is being performed for cosmetic reasons and that no guarantee can be made as to the exact results of this procedure. I understand that every precaution will be taken to prevent complications and that complications from this procedure are rare, they can and sometimes do occur. *
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Although the results are usually dramatic I have been informed that the practice of medicine is not an exact science and that no guarantees can be or have been made concerning the expected results in my case. Multiple treatments may be necessary to achieve optimal results *
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I am 18 years old or older.

Yes, I am 18 years old or older No, I am not 18 years old. I have a parental and/or guardians consent with a signature below.
I am not 18 years old. I have a parental and/or guardians consent with a signature. By signing below you understand all possible risks of this service.

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first and last name
REFUND POLICY: Individual services, promotional services, sale services, series services, gift certificates purchased for yourself or for another individual are absolutely non-refundable.This applies to all of the procedures offered at the salon. There are NO REFUNDS on any procedures or services we have already initiated or already completed. NO EXCEPTIONS. *

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ACKNOWLEDGMENT: BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OFTHIS MICRO-NEEDLING CONSENT FORM AND THAT THE DISCLOSURES REFERRED TO HEREIN WERE MADETO ME. *

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