Micro Needling Consent Form

Micro Needling Consent Form

Thank you for choosing Mako Beauty!
Name

First NameLast Name
Phone Number

Area CodePhone Number
Birthday

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?

Other
What are your main skin care concerns?
Please provide medication you are currently taking or have taken in the last 2 weeks.
I understand the following may be contraindications, and I will notify my provider if any of the following apply to me.
Please provide any allergies you may have.
By marking YES, I affirm I have NOT used Accutane, had Chemotherapy or Radiation treatments in the last 6 months.
By marking YES, I Affirm I have NOT had Botox, dermal filler, laser treatments or cosmetic surgery in the last 2 weeks.
I understand and agree photos may be taken before and after each procedure.
I understand and agree that topical lidocaine may be used by my technican for pain control. I will notify my technician if I have any allergies to anesthetics.
Microneedling may cause pinpoint bleeding and minor bruising on the skin. I understand I must discontinue the use of blood thinners, NSAIDS and vitamin supplements 1 week before treatment, and avoid alcohol and caffeine 48 hours before treatment.
I understand results vary depending on individual factors including medical history, skin type and my compliance with pre/post treatment instructions. I will require a series of treatment to achieve optimal results.
Mako Beauty provides a post care kit and has serums available for purchase which contain ingredients that are safe for use in my aftercare. If I elect to use my own skin care products I understand some of the ingredients may not be suitable for use with microneedling and could cause a dangerous rash or allergic reaction which may have to be medically treated.
Although complications are frequent, I understand the following short term side effects or complications may happen to me. (Check EACH BOX below to signify you had read and agree)
My skin will become red and flushed in apperance similar to a moderate sunburn.
The skin redness may last 24-72 hours. Redness on scar revision can last longer.
I may experience tightness, itchiness, sensitivity, stinging, swelling and heat in the area being treated.
My skin may become very dry, with minor flaking, sloughing, and may have pinpoint scabbing.
Milia may form (white bumps) if I do not use proper post treatment care.
A flare up can occur if I have a history of cold sores.
My skin can (in rare cases) get infected, if I don't follow the proper post treatment care.
I may have an allergic reaction to products used in the treatment.
I have received and reviewed the microneedling pre/post care instrctions and agree to strictly adhere to them.
I understand the procedure, its benifits and its risks. I have been given the opportunity to ask questions, and my questions have been answered satisfactorily. I am aware there may be unforseen complications which may not have been discussed but could result from this procedure. This procedure is elective and I authorize Mako Beauty LLC to perform the selected treatment(s).
I agree to contact Mako Beauty at 828-385-3973 immediately if any problems arise after the treatment including but not limited to rash, extended redness, pain, itching or swelling. I understand any delay in doing so could impair my results or damage my skin.
Date

MonthDayYear
Date
Please provide your electronic signature below and click SUBMIT to complete. Thank you and God Bless!
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Micro Needling Consent Form

Although complications are frequent, I understand the following short term side effects or complications may happen to me. (Check EACH BOX below to signify you had read and agree)