Microneedling Consent Form
Full Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Email Address
example@example.com
Emergency Contact
Which skin issues concern you most about your appearance and your skin? (check all that apply)
Bumpy Skin
Cysts/ Nodules
Dull Complexion
Blackheads
Acne
Acne Scars
Age Spots
Facial Veins
Wrinkles
Breakouts
Large Pores
Melasma
Redness
Sun Damage
Dark Pigmentation
How would you describe your skin?
Dry
Oily
Combination
Sensitive
How would you describe your stress level?
Little
Moderate
Severe
Please select the skin care products you currently are using
Cleanser
Moisturizer
Exfoliater
Toner
Sunscreen
Retinol
Glycolic Acid
INK BEAUTIQUE
Medical Questionnaire
The following conditions are recognized as contraindications for Microneedling and must be disclosed and discussed with the specialist prior to treatment. Please check all that apply and give details below:
Liver disease
Pregnancy Breastfeeding Accutane Treatment
Accutane Treatment
Chemotherapy / Radiation Diabetes Type 1 or Type 2 Any medical condition that causes slow healing or a high risk of infection
Diabetes Type 1 or Type 2
Any medical condition that causes slow healing or a high risk of infection
Are you currently taking any medication?
Yes
No
Please list
Do you have any allergies?
Yes
No
Do you tan in the sun or in tanning beds/booths?
Yes
No
Do you get Laser Treatment or Chemical Peels?
Yes
No
Please check each box to show your understanding and agreement
I am over the age of 18
I am not under the influence of drugs or alcohol.
I desire to receive the indicated Microneedling procedure.
I am not pregnant or nursing.
The general nature of cosmetic skin microneedling treatments as well as the specific procedure to be performed has been explained to me.
If an unforeseen condition arises in the course of the procedure I authorize my therapist to use his/her professional judgment to decide what he/she feels is necessary under the given circumstances.
I fully understand and accept that non-toxic serums are used during the procedure.
I understand and accept that each procedure is a process requiring multiple applications of treatment to achieve desired results and that 100% success cannot be guaranteed during the first procedure.
I understand that I have to return for a repeated procedure after 4 weeks for the results to be successful.
The result of the procedure can be affected by the following: medication, skin characteristics (dry oily sun-damaged thick or thin skin type) personal pH balance of your skin alcohol intake and smoking post procedure after care.
Sunscreen is highly recommended on a daily basis.
I understand that some skin types accept treatment more readily and some skin types can need more than 1 session to achieve the desired look.
I have been informed that the highest standards of hygiene are met and that sterile disposable needles and pigment containers are used for each individual client procedure and visit.
Upon completion of the procedure there might be redness of the skin which will subside within 1-3 days.
Using cosmetics, excessive perspiration and exposure to the sun until the skin has fully healed.
I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Failure to do so may lower my chances for a successful procedure.
I accept the responsibility for determining the desired look and the micro needling procedure as agreed.
I accept full responsibility for the decision to have this cosmetic micro needling done.
I understand the micro needling treatment carries with it known and unknown complications and consequences associated with this type of cosmetic procedure including but not limited to: infection and irritation.
We have your consent to take your photos for education purposes and post them online on my social media.
I give Manmeeth Brar permission to perform my Microneedling procedure. By my signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above.
Signature
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