Procell Screening

Procell Screening
Name*

First NameLast Name
Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you at least 18 years old?*

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

YesNo
Do you have an allergy to Aloe Vera?*

YesNo
Have you taken any mood altering drugs in the past 8 hours?*

YesNo
I understand that if I have a history of cold sores, herpes, or fever blisters that I must take my medication as prescribed by my physician in advance or tell the technician to skip treatment around the lips.
Initial*

Name*

First NameLast Name
Date*

MonthDayYear
Date
I authorize Technician* to perform Microchanneling on my skin and to apply topical preparations as determined necessary.
I understand that Microchanneling is non-ablative skin rejuvenation and involves perforations in my skin to promote healing responses to rejuvenate my skin. I understand that the procedure is performed with an automatic perforating device and that clinical results may vary. I understand there is a possibility of short-term effects such as reddening, peeling, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as infection and scarring. These effects have been fully explained to me.
Initials*
I understand that clinical results may vary depending on individual factors, including medical history, amount of sun damage or textural problems, skin type, and my compliance with pre/post-treatment instructions.
Initials*
I understand that Microchanneling treatment may involve a series of treatments and the fee structure has been fully explained to me.
Initials*
I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final results obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.
Initials*
I confirm that I am not pregnant at this time. I also have completed a medical history checklist and been informed about what I must do and "not do" before, during and after the procedure.
Initials*
I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s).
Initials*
I consent and authorize the use of any photographs of me for the purposes of marketing and education.

YesNo
If no, may we blur out your face and/or tattoos and use the photos that way?

YesNo
I certify that I have been given the opportunity to ask questions and that I have read and fully understand the consents of this consent form.
Initials*
I furthermore indemnify the authorized person herein, and hold harmless from any and all claims, demands, liabilities, judgements, costs and expenses arising out of any claims relating to the procedure authorized herein.
Initials*
Signature*

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