• MICRONEEDLING TREATMENT CONSENT FORM

  • Date of Birth
     / /
  • Format: (000) 000-0000.
  • Microneedling (also known as collagen induction therapy) is a minimally invasive skin rejuvenation procedure that involves the use of a device with fine needles to create controlled micro-injuries to the skin. This stimulates the body's natural wound healing process, resulting in increased collagen and elastin production.

    Treatment Expectations

    Multiple sessions may be necessary to achieve optimal results.

    Improvement in skin texture, tone and appearance may begin to show within 2-4 weeks, with continued improvement

    Results vary per individual and are not guaranteed.

    Temporary redness, sensitivity and mild swelling can be expected immediately post-treatment.

    Possible Risks and Side Effects

    While microneedling is considered safe, potential side effects include but are not limited to:

    redness, swelling, bruising, skin tightness, itching, or tenderness

    mild bleeding or pinpoint scabbing, hyperpigmentation or hypopigmentation (especially in deeper skin tones)

    infection if aftercare instructions are not followed

    allergic reaction to topical products used during or after the procedure

    activation of latent skin conditions (e.g., cold sores)

  •  

    Contraindications 


    Microneedling is not recommended for individuals with the following conditions:

    active acne, eczema, psoriasis or rosacea in the treatment area

    open wounds, sores or skin infections

    history of keloid or hypertrophic scarring

    pregnancy or nursing

    recent use of Accutane (within 6-12 months)

    active cold sores or history of herpes simplex without preventative antiviral medication

    autoimmune diseases or uncontrolled diabetes

    use of blood thinners or current anticoagulant therapy

     

    Pre Treatment Instructions 

    Avoid sun exposure or tanning beds for at least 72 hours before treatment

    Discontinue use of retinoids, AHA/BHA products and exfoliants 3-5 days prior

    Avoid blood-thinning medications or supplements (e.g., aspirin, fish oil) if possible, under physician guidance

    Come to your appointment with clean, makeup-free skin

     

    Post Treatment Care

    Proper aftercare is essential to minimize risks and maximize results:

    Avoid direct sun exposure for at least 72 hours

    Use SPF 30+ daily

    Do not apply makeup for 24-48 hours post-treatment

    Use only approved soothing and hydrating products as recommended by your provider

    Avoid swimming, saunas, and intense exercise for 48-72 hours

    Do not pick or scratch at the skin

    Follow any custom aftercare regimen provided by your provider

  •  

    Failure to follow aftercare may result in complications such as infection or pigmentation issues.

    Client Acknowledgement & Consent I, the undersigned, understand and acknowledge that:

    - I have been informed about the nature of microneedling, expected benefits, potential risks, side effects and alternatives  

    - I have disclosed all relevant medical history and understand the importance of providing accurate information.

    - I have had the opportunity to ask questions and they have been answered to my satisfaction.

    - I understand that individual results may vary and that no guarantee of specific results has been made.

    - I agree to follow all pre and pos treatment instructions provided to me.

    - I understand that although all safety precautions are taken, there are risks associated with any cosmetic procedure.

    - I release and hold harmless my provider and the business, its employees, contractors, and affiliates, from any and all liability, claims, demands, damages, and causes of action arising out of or related to the treatment, including but not limited to allergic reactions, infections, adverse effects, or dissatisfaction with the results. I understand that this is a cosmetic procedure and is non-refundable.

    Photography Consent

    I give permission for photographs to be taken before, during, and after the procedure for documentation, educational, or promotional purposes.

  • Date
     / /
  • Date
     / /
  • Should be Empty: