Microneedling Consent Form

I authorize Viva La Beautyy to perform Micro-Needling treatments for me.

I understand that Micro-needling is a treatment wherein a fine needle will be introduced through the skin. This will combine active ingredients to go deeply into the dermis. Normally, 3-6 treatments are required to see the result.

I understand that I might experience the following side effects and will confirm that it is normal. I also understand that it will go back to normal within 24-48 hours.

Flushed or red skin
The tightness of the skin
Mild sensitivity to touch
Moderate sunburn
Itching and burning

I confirm that I will follow the pre-care and post-care instructions by the specialist.

I understand that this procedure does not guarantee any specific result.

I understand the risks and complications of this procedure and I still like to proceed with it. These are the following risks: infection, hyperpigmentation, allergic reaction, scarring, pain, itchiness, or swelling.

I understand that this procedure or service is non-refundable.

I understand to not use Retionol 5 days prior to the appointment.

I release Viva La Beautyy and its employees from any liabilities hold harmless against damages or accidents that might happen during the procedure.

I confirm that I had the chance to ask any questions about the treatment to the specialist and I receive satisfactory replies.

Overseen by Dr. Hameed preformed by Angelica Blacha

I confirm that I will consult my physician if I have the following contraindications:

Rashes
Acne
Skin infection
Viral, fungal, bacterial infection
Pregnant
Diabetes
Taking NSAIDS, Warfarin, or any anticoagulants

Age

Patient Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Do you have any allergies? If yes, please list them below:

Are you currently taking any medications? If yes, please list them below:

What do you use on your skin? Any acids?

I understand I will not be using any retinal 5 days prior to my appointment.

Are you over 18?

I agree I will not consume any alcohol, or caffeinated drinks 24 hours prior/ after

I do/ do not grant permission for Viva La Beautyy to use photographs and video taken of me on the specified date in the specified location for marketing and publicity purposes. I understand photographs and videos may be used digitally, such as on social media or on the website, brochures, for marketing and publicity purposes! Please selected I do or I do not for the use of photographs or videos during the treatment.

Are you allergic to Lidocaine?

You are agreeing to following the aftercare. After microneedling, your skin is in a sensitive state, so it's important to avoid certain things to ensure proper healing and avoid irritation. Here’s a general list of what to avoid:1. Harsh Skincare Ingredients:Retinoids/Retinol: These can be too harsh on the skin post-microneedling and may cause irritation or excessive dryness. Vitamin C (Ascorbic Acid): Although beneficial for skin, it can be too acidic and irritating immediately after microneedling.AHAs/BHAs (Exfoliants): Chemical exfoliants like glycolic acid, salicylic acid, or lactic acid can irritate and over-sensitize your skin.Benzoyl Peroxide: Can cause excessive dryness and irritation.Fragrance: Products with added fragrance can increase the risk of irritation or an allergic reaction.2. Direct Sun Exposure:- UV Exposure: After microneedling, your skin is more susceptible to sunburn. Avoid direct sunlight and use a high SPF mineral sunscreen (preferably zinc oxide or titanium dioxide) if you must go outside.3. Makeup:- Avoid makeup for at least 24–48 hours post-procedure, as your skin's pores may still be open and vulnerable to bacteria or heavy formulations.4. Heat:- Saunas, Steam Rooms, or Hot Showers: Heat can increase inflammation and sensitivity, which could delay the healing process.- Intense Exercise: Heavy sweating can irritate the skin and expose it to bacteria.5. Scrubbing or Exfoliation:- Physical Exfoliants or Scrubs: Do not use harsh scrubs or exfoliating tools for at least a week. 6. Pool or Saltwater Exposure:- Chlorine and saltwater can irritate your skin, so avoid swimming for a few days after the procedure. 7. Tight Clothing or Headwear:- Avoid tight hats, scarves, or anything that may rub on your treated skin, potentially causing irritation. 🫧 AFTER: What to Look for in Skincare Post-Microneedling:For healing, consider using soothing, hydrating, and non-irritating products:- Hyaluronic Acid: Helps to hydrate and soothe.- Peptides: Encourage skin repair and collagen production.- Ceramides: Help restore the skin’s natural barrier.- Niacinamide: Soothes inflammation and supports skin healing.- Aloe Vera Gel: Known for its soothing and cooling properties.Always follow your practitioner’s aftercare instructions to ensure the best results.

Signature of the patient

Date Signed

Date

Required Deposit for Service

USDMinimum Deposit

Payment Methods

Credit Card

Apple Pay