MICRO-NEEDLE CONSENT FORM

  • CLIENT INTAKE FORM

  • Date*
     / /
  • Format: (000) 000-0000.

  • CLIENT HEALTH | MEDICAL HISTORY

  • Have you used Accutane, Adapalene, Vitamin A containing topicals in the last year?
  • Are you taking any oral steroids (eg. Predisone, Dexmethasone, etc.)?
  • Are you using any topical creams or oral antibiotics for acne, skin cancers, anti-aging or hyperpigmentation?
  • Do you have form of bleeding disorders or are you taking any anticoagulants (blood thinners)?
  • Do you have any diseases of the central nervous system such as epilepsy?
  • Do you have any autoimmune diseases such as Diabetes, Porphyria or Lupus?
  • Do you have any chronic or acute skin diseases such as Herpes HIV, cold sores, psoriasis, eczema?
  • Do you have skin cancer/melanoma?
  • Have you had chemotherapy in the last 6 months?
  • Do you have any hormonal imbalances?
  • Do you have sun light allergies, sensitivities to the sun or histamine reactions?
  • Have you had any laser resurfacing treatments in the last 4-6 weeks?
  • Do you have any permanent makeup or tattooing in the last 6-8 weeks?
  • Do you have any allergies to medications, food and/or srubstances?
  • Have you had any injectables (Botox, Juvederm, Radiesse, Restylane, Perlane, Sillicone, Sculptra)?

  • I understand, that I have read and completed this questionnaire truthfully. I agree this constitutes full disclosure, and that it supersedes any previous verbal and written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or adverse reactions to treatments received. I am aware that it is my responsibility to inform my Aesthetician of my current medical and health conditions and to update this history. The treatments I receive here are voluntary and I release the Aestheticians of Lux Body Lab from liability and assume full responsibility

  • MICRO-NEEDLE CONSENT FORM

  • IF YOU ANSWERED YES TO ANY OF THE ABOVE, PLEASE LIST HERE THE PROCEDURE, CONDITION, MEDICATION, OR ALLERGY YOU MIGHT HAVE INCLUDING PROCEDURE DATES:Micro-needling is based on the skin's natural ability to repair itself. It creates superficial "micro- channels" to the outermost layer of the skin, inducing the healing process and new collagen production. Micro-needling has been shown to reduce the visibility of acne scars, fine-lines, and wrinkles, diminish hyperpigmentation, and improve skin tone and texture.

    Notify your technician PRIOR TO SIGNING THIS CONSENT if any of the following apply to you:

    Cold sores, warts, open skin lesions, sunburn, extreme sensitivity, dermatitis, rosacea
    Blood thinning medications
    Accutane or generic brand within the past year
    Pregnant or breastfeeding
    Received chemotherapy or radiation therapy
    Collagen Vascular Disease
    Eczema, Psoriasis, or Dermatitis
    Hemophilia/bleeding disorders
    Keloid/hypertrophic scarring
    History of autoimmune disease or any condition that may weaken your immune system

  • I hereby authorize and direct the associates of Lux Body Lab to perform my micro-needling treatments.
  • I understand possible side effects include and are not limited to: slight or extreme, redness, histamine reaction, swelling, tingling, tender, dry, or flaking skin, in rare instances, hyperpigmentation/hypopigmentation, scarring or infection can occur.
  • I understand that there are other options not mentioned here may exist. Risk and potential complications are associated with alternative treatments. Most side effects will gradually diminish overtime as healing may take several days.
  • 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 the complications from his procedure are rare, but they can still sometimes occur.
  • Although the results are usually dramatic, I have been informed the practice of this treatment is not an over night result treatment, and that no guarantees can be or have been made concerning the expected results of my case. Multiple treatments may be necessary to achieve optimal results.
  • I have avoided the following products and procedures, 1 week prior to treatment; topical prescriptions, including, but not limited to Retin A, Tretinoin, Differin, Tazorac, abrasive scrubs, or other exploiting products.
  • I have not had any cosmetic injections within the last two weeks.
  • I understand the improvement of my skin may also be accomplished by other treatments, including laser resurfacing treatments, chemical peels, micro-dermabrasion, and facials.
  • I understand that I should only apply products recommended by my clinician post treatment.
  • Should be Empty: