Microneedling Consent Form (Returning Client <12 Weeks)

Client Consultation Form
Personal/Medical History Form

To ensure you receive the most appropriate Microneedling treatment, please complete the following questionnaire. All information provided will be kept strictly confidential.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Emergency Contact Name*
Full Name
Emegency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Original Procedure*

MonthDayYear
Date of Touch-Up Appointment*

MonthDayYear
Have there been any changes to your health, medical history, or medications since your original appointment?*

YesNo
If Yes (Please explain)*

ACKNOWLEDGMENT

MICRONEEDLING CONSENT FORM AND RELEASE FORM
Please read each statement carefully. By checking each box, you confirm that you understand and agree to the statement.
I, First Name Last Name am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and voluntarily consent to receive the microneedling procedure. I understand the nature, risks, and possible complications of the treatment and acknowledge that I am proceeding of my own free will without being pressured or rushed.
*

I acknowledge that this session is a follow-up microneedling treatment within the recommended timeframe. I understand that similar risks, side effects, and post-treatment care apply as with my previous session(s).
*

I confirm that I have previously completed and signed the full Microneedling Consultation and Waiver Form and continue to agree with all terms and conditions outlined in that form.
*

I confirm that I have been given the opportunity to ask any additional questions and that all of my questions have been answered to my satisfaction.
*

I understand that receiving microneedling treatments is my personal choice. I consent to this follow-up procedure, accept the associated risks, and authorize my technician to take any reasonable actions necessary to perform the treatment safely.
*

I consent to any relevant photographs being taken both before and after the procedures to document the results of the procedures and that they can be used for marketing, informational, and educational purposes as my technician sees fit. I waive any and all rights to any forms of compensation for the use of the photos.
*

I understand that no refunds will be issued after the procedure is performed. If there are any issues with the results, I will communicate with my technician, and they will work with me to determine the best solution, which may involve additional appointments at an additional charge.
*

I understand that my technician has the right to refuse the procedure at any time if they believe it is unsafe, if I do not meet the required health conditions, or if they have any concerns regarding my ability to proceed.
*

I fully understand the information provided above and voluntarily consent to receive this Microneedling follow-up treatment.
*

I understand that Halo Brows & Skin operates inside a private, home-based studio. Access requires climbing stairs, and a private washroom is provided. I voluntarily assume all risks of entering and moving within the property, including both indoor and outdoor areas such as walkways, stairs, driveways, and entrances — including but not limited to tripping, slipping (e.g., due to ice or wet surfaces), or falling. I release Halo Brows & Skin and its owner from any liability for any physical, emotional, mental, or other injuries or harm sustained anywhere on the premises, inside or outside.
*

I acknowledge that the services provided by Halo Brows & Skin involve certain risks. By signing this waiver, I voluntarily assume all responsibility for any physical, emotional, or mental harm or distress that may result from the services, including but not limited to allergic reactions, skin sensitivities, dissatisfaction with results, or any injury sustained on the premises.
*

I agree to hold harmless CHANTAL VINOD and any of his/her affiliates, employers or students for any and all undesirable outcomes of my microneedling procedure in light of the fact that all such procedures are performed in compliance with government health and safety requirements and by a certified micropigmentation technician to the best of their ability and education, and release him/her from any and all liability for any injury, harm or loss of any kind whether it is physical, monetary, mental, emotional or otherwise as a result of the outcome of this procedure. My initials on each of the preceding points indicate that I have read and fully understand the contents of each statement above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself and am happy and confident in proceeding with this service.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Client Consultation Form

ACKNOWLEDGMENT