Chandelier ProCell Consent & Screening Form

Unlock your natural ability to produce and restore healthy hair...

Procell Therapies offers cutting-edge stem cell biotechnology to induce a breathtaking transformation to the appearance of your scalp and hair that can last a lifetime.
Review and complete this form to confirm your eligibility...

Procell is a non-medical, mildly invasive procedure. However certain conditions do apply. Once you complete this form and submit it, your information will be reviewed and a personal consultation will take place or be arranged for a future date.
Applicant Information
Name*

First NameLast Name
Contact Information*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number (Cell Phone Preferred)*

Area CodePhone Number
Email Address*
Hair Regrowth Screening Form

Please note all that apply.
1 - Are you allergic to steel?*

YesNo
Note:

A doctor's note or consent may be required as the micro-channelling needles are made of surgical steel. A patch test may also be required.
2 - Do you have hemophilia?*

YesNo
Note:

If yes, a doctor's note is mandatory
3 - Have you taken Accutane (Isotretinoin) in the last 2 years?
If yes, describe
Note:

Accutane (Isotretinoin) could cause scalp irritation and other side effects. Please consult with a doctor prior to signing the consent form to proceed.
4 - Are you under 18 years of age?*

YesNo
Note:

If yes, written parental consent is required.
5a - How long ago did your hair start to thin / fall out?
Describe
5b - What is the reason for hair thinning or hair loss (if known).
Describe
5c - Are you under a doctor or medical practitioner's supervision to deal with this.

YesNo
6 - Do you take aspirin or blood thinners regularly?

YesNo
Note:

It is recommended that any tablets to be taken, are taken AFTER the procedure to minimize bleeding.
7 - Have you taken any prescribed, mood or mind altering drugs in the past eight (8) hours?
Describe and list if applicable
Note:

It is not recommended that any mood or mind altering drugs / substances (including alcohol / marijuana) be taken at least eight (8) hours prior to doing the procedure. Consent from a doctor may be required.
8 - Do you have a history of cold sores, herpes, shingles or fever blisters?

YesNo
Note:

There are nerves running from the scalp to the lip area so despite this being a slim chance on the scalp, the procedure can / may cause a flareup. It is recommended that a virus blocker is taken 3-4 days prior to procedure and / or wait 3 to 4 days after the flareup has gone. eg Valtrax, Zovirax, Twinrix *Severe cases: doctors note is mandatory in order to proceed.
9 - Are you sensitive to latex?

YesNo
Note:

There is nitrile in the gloves. If it's a mild allergy then an antihistamine can be taken prior to the procedure. However, in serious cases consent from a doctor may be required.
10 - Have you had other hair growth treatments ( PRP, Rogain. Nioxin, etc.)?

YesNo
Describe:
Note: Each treatment requires an individual assessment.
11 - Do you have trouble healing? List all the reasons why:
Note: Diabetes may be one reason why you cannot heal. The procedure can be done with diabetes however, the diabetes MUST be under control. A doctor’s note is preferable. * If the diabetes is not under control, this would be a hard contra indication.
12 - Are you allergic to any metals? Please list them:
13 - Are you currently taking anti-inflammatory medications or steroids?

YesNo
Note:

If yes, there may be more bleeding. Steroids can thin the skin and could affect the healing process.
14 - Do you currently have Diabetes?

YesNo
Note:

Is it under control? If yes, we can proceed with caution and upon your doctor’s approval. A doctor’s note is preferable.
15 - Do you have an issue with bruising?

YesNo
Note:

Typically it will take 2 to 3 days to heal. However, if you bruise easily, you could take closer to 7 days to heal.
16 - Do you have a history of skin disease? (e.g: rosacea psoriasis, ringworm, eczema, etc.)

YesNo
If yes, describe:
Note: If any of these are present on the scalp at the time of the procedure, the service cannot be performed at that time. The session(s) will be re-booked once the condition has cleared up.
17 - Do you have a history of skin sensitivity?

YesNo
If yes, describe:
Note: Can proceed with caution, however, there are no refunds, so the procedure will be performed at client’s risk.
18 - Do you have Hyperpigmentation?

YesNo
19 - Are you currently taking vitamin A or E in any form9

YesNo
Note:

These are potential blood thinners so avoid taking them 24 hours prior to the procedure or take these medications only after doing the procedure.
20 - Have you ever been diagnosed with male or female patterned baldness?

YesNo
If yes, how long ago?
Within the last 5 years? Or longer than 5 years ago? **Note: Chances of success are reduced the longer the diagnosis was made. If scalp is bald with zero hairs and very shiny skin, it is highly probable the procedure will not work.
21 - Are you currently pregnant or nursing?

YesNo
Note:

If you are pregnant or nursing, the procedure cannot be performed during this time. Please rebook 2 to 3 months post pregnancy and 6 months post nursing.
22 - Do you currently have cancer or are you currently having radiation or chemotherapy / last 6 months?

YesNo
Note:

If yes, all treatments must be completed and a doctor’s note is required prior to commencing the procedure.
23 - Do you have a heart condition?

YesNo
Note:

If yes, a doctor’s note is preferable but not mandatory, if the condition is under control.
24 - Do you have Hepatitis?

YesNo
25 - Do you have HIV?

YesNo
26 - Do you smoke?

YesNo
Note:

If yes, healing may take longer.
27 - Do you have a compromised immunity or immune system?

YesNo
Describe:
Note: We can proceed with caution and upon your doctor’s approval. A doctor’s note is preferable.
28 - Are you wearing a wig?

YesNo
Note:

It is advised that a clean (preferably silk) scarf be used instead of the wig at least 24 to 48 hours after the service. If however, a wig has to be placed back on the head post procedure, it is recommended that the wig be washed sprayed using an anti bacterial spray.
Please review or download the Consent Form Here.
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Unlock your natural ability to produce and restore healthy hair...

Review and complete this form to confirm your eligibility...

Applicant Information

Hair Regrowth Screening Form

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