NanoStamp 360 Microchanneling Consent Form

Date

Name

Phone

Format: (000) 000-0000.

Email

example@example.com

I am over 18 years of age

Have you taken aspirin or blood thinners in the past 7 days?

Do you have any allergies?

Yes. List below

Are you on any medications?

Yes. List below.

Do you have a history of cold sores, herpes or fever blisters?

Do you have trouble healing?

Do you have any health issues or medical conditions?

Yes. List below.

Are you currently using Accutane, Retin-A, AHA, or other active skin care products?

Are you allergic to any metals?

Yes. List below.

Are you pregnant or nursing?

Please check any that apply to you

Initials*I am undergoing treatment of my own free will. I agree that this procedure is being performed for cosmetic reasons and that no guarantee can be made as to the exact results of this procedure. I understand that every precaution will be taken to prevent complications and that complications from this procedure are rare, they can and sometimes do occur.

Initials*I understand that no guarantees can be or have been made concerning the expected results in my case. Multiple treatments may be necessary to achieve optimal results.

Initials*I hereby authorize Melissa Hagan to perform NanoStamp 360 (Collagen Induction Therapy). I understand that this procedure is purely elective.

By my signature below, I certify that I have read and fully understand the contents of this consent form, have been given the opportunity to ask questions and that the disclosures referred to herein were made to me.I furthermore indemnify the authorized person herein, and hold harmless from any and all claims, demands, liabilities, judgments, costs and expenses arising out of any claims relating to the procedure authorized herein

I acknowledge that I must adhere to Skin Health with Mel's policies. I understand that cancellations must be done with at least 24 hours notice. Failure to do so will result in the loss of 50% of the total service cost. If cancelled a 2nd time within 24 hours, a 50% charge of the total cost of the service will be charged, and deposit will be required for future services. I acknowledge that ANY no show will result in the loss of a package or 100% of the total service cost. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “ No-show” policy.

Date