Simply Relaxed Procell Microchanneling Consent

Microchanneling Consent
Name

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Address

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Area CodePhone Number
Area you at least 18 years of age?

YESNO
Have you taken aspirin or blood thinners in the past 7 days?

YESNO
Initial here I understand that if I have a history of cold sores, herpes, or fever blisters, that I must take the medication prescribed by my Physician in advance or tell My Esthetician to skip treatments around my lips.
Signature

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Are you sensitive to Latex?

YESNO
Have you had any botox or fillers?

YESNO
If so, when?
Are you currently using Accutane, Retinol, AHA, or any other exfoliating skin care products?

YESNO
Are you pregnant or breastfeeding?

YESNO
Are you currently taking anti-inflammatory medications or steroids?

YESNO
Have you had a Laser Treatment of any type or Chemical Peel?

YESNO
If yes, when?
Are you currently undergoing radiation or chemotherapy?

YESNO
Are you allergic to any anesthetics (any of the “caines”)?

YESNO
If so, which?
Do you have any allergies?

YESNO
If yes, to what?
Check all that apply to you:

Heart conditionHIVAccutane in the last 2 yearsHepatitisSmokerCold SoresHemophiliaHepatitsKeloidsChronic Skin DiseaseAllergic to steelDiabetes (uncontrolled)
I authorize Simply Relaxed LLC to perform Microchanneling on my skin, and to apply topical preparations as determined necessary. I understand that Microchanneling is non-ablative skin rejuvenation & involves the creation of perforations in my skin to promote healing responses to rejuvenate my skin. I understand that the procedure is performed with an automatic perforating device and that clinical results may vary. I understand there is a possibility of short-term effects such as reddening, peeling, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as infection & scarring. These effects have been fully explained to me. Clinical results may vary depending on individual factors, including medical history, amount of sun damage or textural problems, skin type, and my compliance with pre/post treatment instructions. I understand that the Microchanneling treatment may involve a series of treatments and the fee structure has been fully explained to me. I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I confirm that I am not pregnant at this time. I also have completed a medical history checklist and been informed about what I must do and “not do” before, during and after the procedure.
I understand that the taking of before and after photos is a part of the procedure. Initials
I consent and authorize the use of any photographs of me for education or marketing purposes.

YESNO
I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form. I furthermore indemnify the authorized person herein, and hold harmless from any and all claims, demands, liabilities, judgments, costs and expenses arising out of any claims relating to the procedure authorized herein.
Patient Signature*

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