• Clover Beauty LLC

    Treatment Consent

  • Procell Microchanneling Consent

    Please initial to indicate your acknowledgment
  • I understand that Microchanneling is an elective procedure for cosmetic purposes only. I have had the opportunity to ask questions and understand the nature, goals, limitations, and possible complications of this treatment. I have had the opportunity to discuss alternative forms of treatment and understand that results may vary.*

  • CONTRAINDICATIONS

    While Microchanneling treatments are safe and effective for most people, there are some who will not be good candidates for treatment:

    • Diabetes - Unstable diabetes patients should not be treated due to healing problems
    • Active Herpes Simplex in the treatment area - Treatment is possible once the outbreak is healed, however it may be advisable to take prescription strength antiviral medication to keep this condition in remission during the treatment series
    • Dry skin - If your skin is overly dry, you will need to start moisturizing and ensure the condition is under control prior to undergoing any treatments
    • Any active inflammatory skin condition - E.g. eczema, psoriasis, infections, rash, or any type of dermatitis at the treatment site
    • Pregnancy/nursing
  • I understand that if I have a history of cold sores, herpes, or fever blisters I must take my medication prescribed by my physician in advance or tell the technician to skip treatment around my lips.*

  • Medical History

  • Please check if yes:*
  • Please check all that apply to you:*

  • Photo Consent

    Clover Beauty LLC may uses photos from Microchanneling treatments to monitor skin progress. These photos may also be used for marketing on websites, printed marketing, or social media posts. These photographs are used to represent and promote Clover Beauty services. Your identity will remain confidential. You may opt out of photos being posted if you wish.
  • I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s). This is for the Aesthetician's charting purposes and to monitor skin progress. I understand I have a choice whether said pictures are posted on social media/used for marketing purposes.*
  • Do you consent to Clover Beauty LLC using your Microchanneling before and after photos for social media/marketing purposes?
  • I hereby grant permission to Clover Beauty LLC to use any photos taken from Microchanneling treatments for marketing and social media posts. I have read and agree to all terms stated above.*

  • Treatment Consent

  • By signing this form, I authorize Clover Beauty 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 the healing response 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 that 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 have been informed about what I must do and “not do” before, during, and after the procedure.

    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, judgements, costs, and expenses arising out of any claim relating to the procedure authorized herein.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
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