Procell Microchanneling Consent Form
Please read the following information carefully and provide your consent for the microchanneling procedure.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Are you over the age of 18?
Yes
No
Have you taken aspirin or blood thinners in the last 7 days?
Yes
No
Do you have an allergy to Aloe Vera?
Yes
No
Are you pregnant?
Yes
No
Do you have diabetes? (Patients with diabetes should not be treated due to healing issues)
Yes
No
Do you have active Herpes Simplex in the treatment area? (Treatment is possible once the outbreak has healed)
Yes
No
Do you have any of the listed active inflammatory skin conditions?
Eczema
Psoriasis
Rosacea
Other
Are you sensitive to latex?
Yes
No
In the last 30 days, have you had a chemical or laser peel?
Yes
No
Do you have trouble healing?
Yes
No
In the past 30 days, have you had any Botox or fillers?
Yes
No
Are you currently undergoing radiation or chemotherapy?
Yes
No
Are your currently using:
Accutane
Retin-A
AHA
None of the above
Are you allergic to any metals? (If yes, please list in “other” option)
Yes
No
Other
Are you currently taking anti-inflammatory medications or steroids?
Yes
No
Do you have a history of skin disease?
Yes
No
Do you have a history of skin sensitivity?
Yes
No
Are you currently taking vitamin A or vitamin E in any form?
Yes
No
Are you currently being treated by a dermatologist or physician? If yes, please select all that apply.
Heart condition
Hyperpigmentation
Hepatitis
HIV
Cold sores
Accutane is the last 2 years
Diabetes (uncontrolled)
Keloid above neck
chronic skin disease
Allergic to steel
Hemophilia
None of the above
Are you currently taking any medications? If yes, please specify.
Do you have any known allergies or sensitivities?
Have you previously undergone microchanneling or similar treatments?
Yes
No
I understand that microchanneling is a cosmetic procedure that involves creating micro-injuries to the skin to promote healing and rejuvenation.
I understand and agree
No, I do not understand
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 & scarring.
I understand and agree
I do not agree
I acknowledge that results may vary between individuals and that there is no guarantee of specific results from the treatment.
I understand and agree
No, I do not understand
I understand that the Microchanneling treatment may involve a series of treatments and the fee structure has been fully explained to me.
I understand and agree
I do not agree
I have had the opportunity to ask questions regarding the procedure and have received satisfactory answers.
Yes
No
I consent to the Microchanneling procedure and agree to follow all pre and post-treatment instructions provided by my practitioner.
I understand and agree
No, I do not understand and agree
Brain Dump: please use this section to tell me anything and everything you want me to know about your skin.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
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