Nano Needling Consent Form
Please read the following information carefully and provide your consent for the nano needling 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
2 digit month, 2 digit day, 4 digit year
Date
Have you previously undergone microchanneling or similar treatments?
Yes
No
Do you have any known allergies or sensitivities?
Do you have any existing skin conditions (e.g., eczema, psoriasis, etc.)?
Are you currently taking any medications? If yes, please specify.
Are you pregnant or nursing?
Yes
No
I understand that nano needling is a non-invasive skincare treatment that uses a specialized pen with microscopic silicone. It gently creates tin, shallow channels on the skin's surface.
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 acknowledge and accept
I do not accept
I have had the opportunity to ask questions regarding the procedure and have received satisfactory answers.
Yes
No
I consent to the nano needling procedure and agree to follow all pre and post-treatment instructions provided by my practitioner.
I consent
I do not consent
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: