Client Consent Microneedling

Please read and initial where indicated

Microneedling devices Intentionally create very superficial "micro-injuries" to the outermost layer of the skin, inducing the healing process including new collagen production. Microneedling has been shown to reduce the visibility of acne scars, fine lines, and wrinkles, diminish hyperpigmentation, and improve skin tone and texture, resulting in smoother, firmer, younger-looking skin. Skin needling treatments are performed in a safe and precise manner with sterile devices and are normally completed within 30-60 minutes, depending on the selected area.

Although, the majority of patients do not experience any complications with microneedling, It is important you understand that risks do exist. The microneedling procedure is minimally invasive, utilizing a set of microneedles to inflict multiple, tiny, puncture/lacerations to the outermost layer of the skin. Because microneedling penetrates the skin, it inherently carries health risks, including but not limited to those listed below. You should discuss any and all health concerns with your esthetician or attending healthcare provider PRIOR to signing this consent form.*

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I understand that microneedling may cause infection, pigment/color change, scarring, pain, persistent redness, itching, and/or swelling, and/or an allergic reaction. *

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I understand that after the procedure, the skin will be red, with mild swelling and/or bruising, and might feel tight and sensitive to the touch. Although these symptoms may take 2-3 days to resolve completely, they will diminish significantly within a few hours after treatment. *

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I understand contraindications that would preclude me from receiving microneedling treatments including active acne, active infection of anytype (bacterial, viral, or fungal), cardiac disease/abnormalities,collagen vascular disease, eczema, psoriasis, or dermatitis, hemophilia/bleeding disorders, keloid/hypertrophic scaring, pregnancy/lactation,raised lesions (moles, warts, etc, skin cancer, sunburn, tattoos, telangiectasia/erythema, uncontrolled diabetes,vascular lesions (hemangiomas), rosacea, and scleroderma.*

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I understand that the use of Botox®, Juvederm®,Restylane®, and any other injectable must be disclosed prior to treatment.*

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I understand that there are some contraindicated medications: blood thinner medications, chemotherapy or radiation, hormone replacement therapy, recent use of some topical medication. *

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I understand that microneedling is contraindicated within 72 hours of waxing, and within 1-3 weeks of a chemical peel.*

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I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.*

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I understand that it is imperative to my health that I disclose all of the information requested in the Client Consultation/Health History.*

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I have cited all conditions and circumstances regarding my health history, medications being taken, andany past reactions to products or medications. *

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I understand that I MUST avoid sun exposure for 1 to 2 weeks after a micro-needling treatment. I should also wear a daily SPF.*

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I consent to "before and after" photographs for the purpose of documentation potential advertising, and promotional purposes.*

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IMPORTANT INFORMATION – Microneedling Consent

I understand that if I have any concerns before, during, or after treatment, I will communicate them directly with my skincare specialist.

I give my full consent for Gabriela Garcia, my licensed skincare specialist, to perform the microneedling procedure as discussed. I release and hold her harmless from any liability that may arise as a result of this treatment.

I confirm that I have accurately provided all relevant health information, including known allergies, medical conditions, prescription medications, and any topical or oral products I am currently using.

I acknowledge that every effort will be made by my skincare specialist to minimize or prevent adverse reactions. However, I understand that individual responses to treatment may vary, and results are not guaranteed.

Should I have any further questions or concerns following the procedure, I agree to consult my skincare specialist promptly.

I acknowledge that this form constitutes full and complete disclosure, superseding any previous verbal or written communications.

I certify that I have read and fully understand the statements above, and that I have had the opportunity to ask questions and receive appropriate explanations. I understand the nature of the procedure and voluntarily accept all risks involved.

I do not hold Gabriela Garcia responsible for any conditions that were present but not disclosed at the time of treatment, which may be affected by the procedure performed today.

Client First & Last Name:*

I acknowledge and agree to the Microneedling Consent Important Information.

Client Full Name (Signature)*

Date*

Date

Skin & Massage Spa By Bella

3881 W 3500 S Suite #118

West Valley City, Utah 84120

skinspabybella@gmail.com

801-837-8304

www.skinandmassagespabybella.com

Informed Consent: Microneedling