Micro channeling & nano infusion
Micro channeling and Nano infusion
Name
First Name
Last Name
Email
example@example.com
Date
-
Month
-
Day
Year
Date
Are you at least 18 years of age
yes
no
Have you taken blood thinners in the past 7 days?
yes
no
Do you have any allergies?
yes
no
Are you on any medications?
yes
no
Do you have a history of cold sores?
yes
no
Do you have trouble healing?
yes
no
Do you have any health issues/ medical conditions?
yes
no
Are you using any anti aging or anti acne skincare? Accutane?
yes
no
Are you allergic to any metals?
yes
no
Are you allergic to any anesthetics?
yes
no
Are you pregnant or nursing?
yes
no
Are you diabetic?
yes
no
Do you have bleeding disorders?
yes
no
Are you currently on chemotherapy/ radiation?
yes
no
Any botox/ fillers in the last 2 weeks?
yes
no
Do you have any cardiac irregularities
yes
no
Do you have auto immune disorder?
yes
no
Do you have any active infections?
yes
no
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_
initial
I understand that no guarantees can be or have been made concerning the expected results in mycase. Multiple treatments may be necessary to achieve optimal results.
Initial
I hereby authorize Lash Habit Academy staff and or students or any delegated associates to perform NanoStamp 360 (Collagen Induction Therapy). I understand that this procedure is purely elective
Initial
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.
Initial
Signature
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