Chemical Peel And Microneedling Consultation Form

If getting Microneedling Treatment
- I authorize MicroMoon Skin Studio to perform Micro-Needling treatments for me.
- I understand that Microneedling is a minimally invasive procedure for your skin. Your Esthetician uses thin needles to make tiny holes in the top layer of your skin. The damage helps stimulate your skin’s healing process, producing more collagen and elastin. These proteins keep your skin firm and smooth. Usually, 3-6 treatments are required to see some changes in your skin.
- I understand that I might experience the following side effects and will confirm that it is normal. I also know it will return to normal within 24-48 hours.
Flushed or red skin
The tightness of the skin
Mild sensitivity to touch
Moderate sunburn
Itching and burning
- I confirm that I will follow the pre-care and post-care instructions by the specialist.
- I understand that this procedure does not guarantee any specific result.
- I understand the risks and complications of this procedure, and I still like to proceed with it. These are the following risks: infection, hyperpigmentation, allergic reaction, scarring, pain, itchiness, or swelling.
- I understand that the deposit for this procedure or service is non-refundable.
- I confirm that I will consult my physician if I have the following contraindications:
Rashes
Acne
Skin infection
Viral, fungal, or bacterial infection
Pregnant
Diabetes
Taking NSAIDS, Warfarin, or any anticoagulants
I understand everything mentioned above:
Initials required

Post Treatment Guidelines
I understood the Post-treatment guideline
Yes or no
For chemical Peels: I understand that I may experience some skin tightening during treatment and after, which may last for several days. Darkening and flaking may occur, lasting for 3 to 10 days. It is recommended that you do not pick or peel the flaking skin off as it may scar. Skin renewal may take longer than usual than the other parts. During the post-treatment, it is highly important to do the following: Apply sunscreen for daily protection, we require at least an SPF 30+ sunscreen to be used. Please do not apply makeup immediately after treatment. Avoid any physical activity that could increase your blood circulation to the face within 24 hours after treatment. Avoid direct sun for 2-3 weeks after treatment. Do not use any other products on your treated skin area for at least 72 hours. As stated above, do not pick or peel loose or flaking skin. Keep away from heat sources.

For Microneedling:

What will I look like after treatment?
• Immediately after the treatment, your skin will be red and flushed with an appearance similar to moderate sunburn. You may experience skin tightness and mild sensitivity to touch to the area being treated. The redness will diminish greatly after a few hours following the treatment, and within 24 hours, the skin will be generally calmed.
• If you have treatment around your eyes, you may experience micro-bruising lasting for 3-4 days. This can be covered in make-up.
• Do not take any anti-inflammatory medications such as Ibuprofen, Motrin, and Advil. These agents will interfere with the natural inflammatory process that is critical and responsible for skin rejuvenation.
• Do not exercise for 24-48 hours post-procedure to minimize the risk of blistering.
• Within two days following your Microneedling procedure, you will notice skin dryness and flaking. This is due to an increased turnover of skin cells. During this time, we recommend that you apply a hydrating
moisturizer.

How should you take care of my skin?
• Immediately After Treatment: Cleanse with a gentle cleanser daily. Gently pat dry. If your skin feels dry or tight, apply a gentle moisturizer. Avoid partaking in activities that will heat up your skin, such as going in a hot tub/Jacuzzi/sauna, taking a very hot shower, or strenuous exercise for 2 days after treatment.

• First Few Days: Continue gentle cleansing and moisturizing over the next few days. Avoid scrubbing, rubbing, or using exfoliants for 1 week. Apply sunscreen daily, and you can use makeup if needed starting the day after treatment.
• First Week of Healing: Keep the treated area clean; avoid smoking, excessive alcohol consumption, excessive exercise, sweating, swimming, or exposing skin to heat and sun.
• Skin Care Products: Your skin care products should be non-irritating and non-clogging for the first week after treatment. Moisturizer should be applied one to two times per day.
• Scrubs, Toners, Glycolic Acid, and retinoids: Your skin will be sensitive for the first week or two after treatment. Do not use products that will irritate you during this time. Please do not use any scrubs, toners, glycolic acid, retinoids (RetinA or retinol), or bleaching creams (hydroquinone) until your skin has healed unless otherwise directed by your doctor.
• Sunscreen: You must use sunscreen to prevent discoloration and sun damage to the skin while it is healing. Use sunscreen daily for at least 3 months after your last treatment. The sunscreen should offer broadband protection (UVA and UVB) and have a sun protection factor (SPF) of 30 or more. Apply sunscreen 20 minutes before going outside and reapply sunscreen every 2 hours. If direct sun exposure is necessary, wear a hat and clothing that covers the treated area.
• Abnormal Healing: If you notice any pimples, blisters, cuts, bruises, crusting/scabs, areas of raw skin, ulcerations, active bleeding, increased discomfort or pain, pigment changes (lighter or darker than usual complexion) or any other problems, please contact us as soon as possible.
• A week after your microneedling treatment, most patients note that their skin is smoother and more radiant.
Acknowledgement of Risks and Liability

WARNING: THIS AGREEMENT WILL AFFECT YOUR LEGAL RIGHTS. READ IT CAREFULLY!
Thank you for trusting us with your skincare journey! As part of the treatment, we include an agreement that clarifies our commitment to your safety, as well as your understanding of the treatment and any associated risks. This waiver includes a release from liability, an assumption of any possible risks, and an agreement not to pursue claims related to the treatment, ensuring a clear, mutual understanding for both of us.

Please initial:

I understand that, although uncommon, some risks and complications may be associated with a chemical peel or microneedling treatment. My esthetician will take every step to ensure that my experience is as safe and positive as possible. I acknowledge that I have been informed about possible side effects, which may include redness, blisters, or dryness, as well as what to expect as my skin heals (like temporary dryness, irritation, or peeling).
I understand that this chemical peel and Microneedling procedure is expected to make the skin feel uncomfortable while applied/doing but agree to inform the skin therapist immediately if I have questions, concerns, or am overly uncomfortable during treatment or after I return home. In the event that I may have additional questions or regarding my treatment or the suggested home product/post treatment care, I will consult my skin immediately. I understand that if I choose to consult a physician, that I do So at my own expense.
Your initials
Informed Client Consent:
I understand that I should not have a chemical peel or Microneedling treatment if I intend to continue to have excessive sun exposure. been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and require regular use of sunscreen.
I understand and agree to follow the home care instructions and recommendations provided by my esthetician. I understand that I will be responsible for following home regimens that can minimize or eliminate possible reactions, including recognizing the importance of adhering to a sunscreen, avoiding the sun/tanning avoiding extreme weather conditions, avoiding excessive exercise, and using a moisturizer specifically recommended to me by my esthetician. I realize and accept that the consequences of failure to adhere to these instructions may yield undesirable results.
Your initials
I understand that results are not guaranteed and for maximum results, more than one treatment may required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/ environmental damage, pigmentation levels, or acne conditions.
Your initials
I am aware that there are inherent and significant dangers, hazards and risks associated with the service. I am aware that the Risks include but are not limited to injury from physical equipments, products used, performing a skill incorrectly, or potentially any obstacles, conditions on the floor or anything in the environment
I acknowledge my obligation to inform the esthetician if I feel any pain, discomfort, fatigue or any other symptoms. I understand that I can stop the treatment any time, and have the right to immediately leave the space.
"I acknowledge that while every effort has been made to ensure my safety during this treatment, there are inherent risks involved that cannot be completely eliminated. I understand and accept that by proceeding, I am taking personal responsibility for these risks, which could include injury or other unforeseen issues, despite all measures taken by the company, esthetician, and staff to make this experience safe and beneficial. By signing below, I agree to proceed with this treatment with a full understanding of the terms outlined here, even in the rare event of unforeseen circumstances.
In choosing to receive a treatment at Micromoon Skin Studio Ltd., I understand and agree to the following:a) I acknowledge that Micromoon Skin Studio Ltd. will take all reasonable measures to ensure my comfort and safety during my visit. I release the studio and its team from any claims that I or my legal representatives might have, both now and in the future, related to this treatment.b) I understand that while every effort will be made to provide a safe and beneficial experience, unforeseen events or outcomes may arise. I therefore agree to release Micromoon Skin Studio Ltd. and its staff from any liability related to potential personal injuries, property damage, or other losses connected to my treatment, including circumstances where unintended factors, honest mistakes, or any unforeseeable circumstances may come into play.
I understand that by receiving this treatment at MicroMoon Skin Studio LTD, I am accepting responsibility for my own health and well-being. I agree to release and hold harmless MicroMoon Skin Studio LTD from any claims, damages, or costs that may arise from the treatment. I acknowledge that this is a standard part of the process to ensure the best care is provided.
I confirm that I have had sufficient time to read and understand each term in this waiver in its entirety, and have agreed to the terms freely and voluntarily. I duly authorize the Esthetician/Technician to perform the treatment for me, as well as any post-treatment requirements that may be necessary. I understand that this waiver is binding on myself and my Legal Representative.
Cancellation Policy
At MicroMoon Skin Studio LTD, we aim to provide seamless scheduling and the best possible service to all our clients. Please review the details of our Reservation & Cancellation Policy below:Deposit Requirement:A $50 deposit is required for all current and future appointments.Appointment Confirmation:Please confirm your appointment when you receive a reminder from Square or our team.Cancellation or Changes Under 48 Hours:Cancellations or changes made less than 48 hours before your scheduled appointment will incur a $50 cancellation fee. Additionally, a new $50 deposit will be required for rescheduling.Minimum Notice Requirement:We kindly request a minimum of 48 hours' notice for any cancellations or changes to your appointment.No-Show Policy: (also for changes made or cancellations on the same day)If you do not attend your scheduled appointment without prior notice, a charge equal to 100% of the treatment cost will apply.By providing your credit card details and scheduling an appointment with MicroMoon Skin Studio LTD, you acknowledge and agree to the following:You understand the reservation and cancellation policies.You consent to having your credit card charged or your deposit retained if you fail to provide at least 48 hours’ notice for cancellations or changes to your appointment.This policy helps us maintain service availability and ensure the best care for all our clients. If you have any questions or concerns, please don’t hesitate to contact us.Thank you for choosing MicroMoon Skin Studio LTD. We look forward to serving you.
Initials required
Client Name (Printed)
Signature
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Chemical Peel And Microneedling Consultation Form

If getting Microneedling Treatment

Post Treatment Guidelines

Acknowledgement of Risks and Liability