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 (Print Name) hereby authorize and direct Gangnam Spa LLC to perform my Micro-needling treatments.
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 CLINICIAN POST TREATMENT.
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.
Most side effects will gradually diminish over time as healing may take several days. Notify your clinician 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:
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Topical prescriptions including but not limited to Retin-A, Tretinoin, Differin, Tazorac
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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.
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.
ACKNOWLEDGMENT
BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS MICRONEEDLING CONSENT FORM AND THAT THE DISCLOSURES REFERRED TO HEREIN WERE MADE TO ME.
Print Name:
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Date: 
Technician’s Signature ![]()
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Microneedling Pre- and Post- care instructions
Prior to the Microneedling session, please observe the following:
•No Retin-A products or applications 24 hours prior to your treatment.
•No auto-immune therapies or products 24 hours prior to your treatment.
•No prolonged sun exposure to the face 24 hours prior to your treatment. A Microneedling treatment will not be administered on sunburned skin.
•On the day of the treatment, please keep your face clean and do not apply makeup.
•If you are taking a blood thinner, aspirin or any other medication that you have the propensity to bleed easily while on, please tell your technician. If you are under a physician’s care and need to discontinue your medication for a few days, always ask your physician prior to each Microneedling appointment.
•If you are planning to receive Botox, make sure that you give yourself at least 2 weeks post Botox injections before receiving your Microneedling procedure.
•If an active or extreme breakout occurs before treatment, please consult your practitioner. Wait 6 months following oral isotretinoin use. After your treatment, please be aware and observe the following:
•Immediately after your treatment, you will look as though you have a moderate to severe sunburn and your skin may feel warm and tighter than usual. You may also notice some slight swelling, both are normal and should subside after 1 to 2 hours and will normally diminish within the same day or 24 hours. You may see slight redness after 24 hours but only in minimal areas or spots.
•If you are concerned about any reaction, please call our office and contact your healthcare provider immediately.
After-care instructions for MicroNeedling Treatment:
•Use tepid water for the initial 24 hours to rinse the treated area. After 24 hours, use a gentle cleanser to cleanse the face for the following 72 hours and gently dry the treated skin. Always make sure that your hands are clean when touching the treated area.
• Apply the only stemcell products (recommended by us) for moisture over the next 24 hours.
•Do not take any inflammatory medicines for at least 2 weeks post treatment.
•It is recommended that makeup or sunscreen should not be applied for 24 hours after the procedure. Do not apply any makeup with a makeup brush, especially if it is not clean.
• After the initial 24 hours, apply a broad spectrum UVA/UVB sunscreen with a minimum SPF 30 for two weeks. A chemical-free sunscreen is highly recommended.
What to Avoid:
•For at least 3 days post treatment, do NOT use any Alpha Hydroxy Acids, Beta Hydroxy Acid, Retinol (Vitamin A), Vitamin C (in a low pH formula) or anything perceived as ‘active’ skincare.
•Avoid intentional and direct sunlight for 48 hours. No tanning beds.
•Do not go swimming for at least 24 hours post-treatment.
•No exercising or strenuous activity for the first 24 hours post-treatment. Sweating and gym environments must be avoided during the first 72 hours post-treatment