Microneedling Consent Form

Patient Name

First NameLast Name

Gender

Date of Birth

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

Emergency Contact

First NameLast Name

Phone Number

Please enter a valid phone number.

Relationship to Client

Do you have any allergies or hypersensitivities ? If yes, please list them below:

Do you have any known dermatological history (acne, herpes, etc.) If yes, please list them below:

Are you currently taking any medications or supplements? If yes, please list them below:

Recent or chronic infection history:

Disease affecting the immune system or thyroid gland; or family history of auto-immune disease:

What is the purpose of this form?
The purpose of this form is to help inform you and to help you decide if you want to have this procedure done to you.
You should take part in the procedure only if you want to.
Before you decide if you want to take part in this procedure, it is important that you read the information below. This form may use words you do not understand.

Description of the Procedure
SkinPen®, the first-to-market and U.S Food and Drug Administration-cleared microneedling device clinically-proven solution to safely and effectively improve the appearance of facial acne scars for people age 22 and above. The SkinPen also improves the appearance of wrinkles on the neck.
Microneedling procedures are performed in a minimally-invasive (little to no introduction of the instrument into the body) and precise manner with the use of the sterile needle head. The procedure is normally completed within 30-60 minutes, depending on the required procedure and anatomical site

Patient Consent
I understand that results of microneedling procedures will vary among individuals.
I understand that although I may see a change after my first procedure, I may require a series of sessions to obtain my desired outcome.

The procedure and side effects described in this consent and included on Saucy Esthetic's Website have been explained to me including alternative methods, as have the advantages and disadvantages of microneedling.

I have been advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated, therefore, there can be no guarantee as expressed or implied either as to the success or other results of the microneedling procedure. I am aware that the microneedling procedure is not permanent and natural degradation may occur over time.

I confirm that I will follow the pre-care and post-care instructions by the specialist.

I understand the risks and complications of this procedure and I still like to proceed with it. These are the following risks: infection, hyperpigmentation, allergic reaction, scarring, pain, itchiness, or swelling.

I understand that this procedure or service is non-refundable.

I release Saucy Esthetics and its employees from any liabilities and hold harmless against damages or accidents that might happen during the procedure.

I confirm that I will consult my physician if I have any contraindications

I have read (or it has been read to me) and I understand this consent and I understand the information contained in it

I have had the opportunity to ask any questions about the microneedling procedure including risks or alternatives, and I acknowledge that all my questions about the procedure have been answered in a satisfactory manner.

Signature of the patient

Date Signed

Date