Micro-needling consent form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
*
Website
Instagram
Facebook
Web search
Friend / Referral
If Refferal, who?
What are your main skin concerns
*
Acne scars
Hyperpigmentation
Fine lines / Wrinkles
Crepey / Loose skin
Texture / Pores
Stretch Marks
Please provide medication you are currently taking or have taken in the last 2 weeks?
*
Please provide any allergies you may have.
*
By marking YES, I affirm I have not used Accutane, had chemotherapy or radiation in the last 6 months.
*
Yes
No
By marking YES, I affirm I have NOT had Botox, dermal filler, laser treatments or cosmetic surgery in the last 2 weeks.
*
Yes
No
I understand and agree photos may be taken before and after each procedure.
*
Yes
No
I understand and agree that topical lidocaine may be used by my technican for pain control. I will notify my technician if I have any allergies to anesthetics.
*
Yes
No
Microneedling may cause pinpoint bleeding and minor bruising on the skin. I understand I must discontinue the use of blood thinners, NSAIDS and vitamin supplements 1 week before treatment, and avoid alcohol and caffeine 48 hours before treatment.
*
Yes
No
I understand results vary depending on individual factors including medical history, skin type and my compliance with pre/post treatment instructions. I will require a series of treatment to achieve optimal results.
*
Yes
No
Esthetics By Christa provides a post care kit and has serums available for purchase which contain ingredients that are safe for use in my aftercare. If I elect to use my own skin care products I understand some of the ingredients may not be suitable for use with microneedling and could cause a dangerous rash or allergic reaction which may have to be medically treated.
*
Yes
No
Although complications are infrequent, I understand the following short term side effects or complications may happen to me. (Check EACH BOX below to signify you had read and agree)
My skin will become red and flushed in apperance similar to a moderate sunburn.
*
Yes
The skin redness may last 24-72 hours. Redness on scar revision can last longer.
*
Yes
I may experience tightness, itchiness, sensitivity, stinging, swelling and heat in the area being treated.
*
Yes
My skin may become very dry, with minor flaking, sloughing, and may have pinpoint scabbing.
*
Yes
Milia may form (white bumps) if I do not use proper post treatment care.
*
Yes
A flare up can occur if I have a history of cold sores.
*
Yes
My skin can (in rare cases) get infected, if I don't follow the proper post treatment care.
*
Yes
I may have an allergic reaction to products used in the treatment.
*
Yes
I have received and reviewed the microneedling pre/post care instructions and agree to strictly adhere to them.
*
Yes
No
I understand the procedure, its benefits and its risks. I have been given the opportunity to ask questions, and my questions have been answered satisfactorily. I am aware there may be unforseen complications which may not have been discussed but could result from this procedure. This procedure is elective and I authorize Esthetics by Christa LLC to perform the selected treatment(s).
*
Yes
No
I agree to contact Esthetics by Christa at 828-400-8019 immediately if any problems arise after the treatment including but not limited to rash, extended redness, pain, itching or swelling. I understand any delay in doing so could impair my results or damage my skin.
*
Yes
No
Date
*
-
Month
-
Day
Year
Date
Please provide your electronic signature below and click SUBMIT to complete. Thank you and Have a wonderful day!
*
Submit
Submit
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