• Microchanneling Consent Form

  • Birthdate*
     / /
  • Format: (000) 000-0000.
  • I am over 18 years of age*
  • Have you taken aspirin or blood thinners in the past 7 days?*
  • Do you have any allergies?*
  • Do you have a history of cold sores, herpes or fever blisters?*
  • Do you have trouble healing?*
  • Are you pregnant or nursing?*
  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
  • Are you allergic to any metals?*
  • Are you allergic to any anesthetics?*
  • Please select all that apply to you*

  • 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.

    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.

    I hereby authorize Radiant Skin Spa or any delegated associates 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.

    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.

  • Date*
     / /
  • Should be Empty: