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.*

Initials

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

I understand that if I have any concerns, I will address these with my skin care specialist.
I give permission to Gabriela Garcia, my skincare specialist to perform the microneedling procedure we have discussed, and will hold her harmless from any liability that may result from this treatment.
I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically.
I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible.
In the event I may have additional questions or concerns regarding my treatment, I will consult the skin care specialist immediately.
I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures.
I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.
I understand the procedure and accept the risks. I do not hold the skin care specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

Client Name (Printed).*

Client Name (Signature)*

Date*

Date

Skin & Massage Spa By Bella

3881 W 3500 S Suite #118

West Valley City, Utah 84120

skinandmassagespabybella@gmail.com

801-837-8304

www.skinandmassagespabybella.com

Informed Consent: Microneedling