BB GLOW

Glam Body Sugaring Boutique Microneedling|Nanoneedling / BB Glow Consent Form
Full Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Birth Date *

Month Day Year
Gender *
E-mail
Emergency Contact *
Emergency Contact Phone Number *
How were you referred to our boutique?
Contraindications

Although it is impossible to list every potential risk and complication, the following are recognized as known contraindications to microneedling. Furthermore, it is your responsibility to fully and accurately disclose allmedical history prior to initial treatment, as well as to provide any necessary updates at all future treatmentsessions. If you have any of the conditions listed below, you should bring it to the attention of your estheticianor healthcare provider PRIOR to signing this consent form.
SCARRING – Although normal healing after the procedure is expected, abnormal scars may occur in both the skin and deeper tissues. In rare cases, thickened or keloid scars may result, especially if you are prone to keloid scarring anyway. Scars may be unattractive and of different color than surrounding skin. Additional treatments may be needed to treat scarring.

PAIN – There may be a very slight burning, scratchy, and irritated sensation to the skin. This is usually temporary and is gone within a few hours after treatment. A sudden reappearance of redness or pain is a sign of infection, and you should notify our office immediately.

PERSISTENT REDNESS, ITCHING, AND/OR SWELLING – Itching, redness, and swelling are normal parts of the healing process. These symptoms rarely persist longer than 24 hours. However, treatments received less than 4 weeks apart may induce prolonged symptoms.

ALLERGIC REACTION – Micro-needling is performed with a device whose head contains 12 sterile, hypodermic needles, which makes an allergic reaction nearly impossible. However, in conjunction with the micro-needling procedure a variety of products may be used on the face; those products could cause an allergic reaction. Additionally, since micro-needling increases the penetration of topical substances, it could cause you to become hypersensitive to products used on the face. If an allergic reaction were to occur, you must contact our office immediately, as it may require further treatment.

LACK OF PERMANENT RESULT – Micro-needling will not completely or permanently improve skin texture, tone, elasticity, hyperpigmentation, or scars, or minimize fine lines and wrinkles. It is important that your expectations be realistic and you understand that the procedure has its limitations. Additional procedures may be necessary to achieve your desired effect.

UNSATISFACTORY RESULT – Although rare from micro-needling, there is a possibility of a poor result from any cosmetic procedure. Micro-needling may induce undesirable results, including but not limited to skin sloughing, scarring, permanent pigment change, and/or other undesirable skin changes. There is always a possibility that you may be disappointed with the final results of micro-needling.
Are you experiencing any of the following? (Please check all that apply)

Active Acne Collagen Vascular disease Keloid/ hypertrophic scarring Active infection of any type (viral, bacterial, fungal) Eczema, Psoriasis or Dermatits Raised lesions or moles Blood thinner medications Hempophlia/ blood disorders Recent Chemical peel cardiac irregularities Hormone Replacement Recent use of topical rx chemotherapy or radiation roseacea Schleroderma skin Cancer Sunburn Tattoos Uncontrolled Diabetes Vascular Lesions
What medications or drugs are you taking?
List any other health problems, no matter how insignificant they may be:
Purpose of this appointment and areas of concern?: *
Introduction to Microneedling, NanoNeedling and BB Glow
INTRODUCTION TO MICRONEEDLING & THE DERMA-PEN & BB Glow

The concept of micro-needling is based on the skin’s natural ability to repair itself when it suffers physical damage such as cuts, burns, abrasions or other injuries. Immediately after an injury to the skin, our body begins the healing process, triggering new collagen synthesis. The DERMA-PEN is a micro-needling device that intentionally creates very superficial “micro-injuries” to the outermost layer of the skin to induce the healing process that includes new collagen production. Micro-needling has been shown to reduce the visibility of acne scars, fine lines, and wrinkles; diminish hyper-pigmentation; and improve skin tone and texture, resulting in smoother, firmer, younger looking skin.

ABOUT THE PROCEDURE

Micro-needling is performed using DERMA-PEN. The DERMA-PEN micro-needling with BB Glow serum procedure is performed in a safe and precise manner with a single-use, sterile needle head. The treatment session usually takes about 30- 60 minutes, depending on the area(s) being treated. Throughout the procedure, activating agents will be applied to stimulate rejuvenation process. Then a hydrating facial mask will be applied for hydration. After the procedure, your skin will be red with mild swelling and/or bruising, and it might feel tight and sensitive to the touch. Although these symptoms may take 2-3 days to resolve completely, they will diminish significantly within a few hours after treatment.

RISKS OF MICRO-NEEDLING

Although the majority of patients do not experience any complications with micro-needling, it is important you understand that risks do exist. The micro-needling procedure is minimally invasive and uses a set of micro- needles to inflict multiple, tiny, punctures/lacerations to the outermost layer of the skin. Because micro- needling penetrates the skin, it inherently carries health risks, including but not limited to those listed below. You should discuss any and all health concerns with your esthetician or attending healthcare provider PRIOR to signing this consent form.

INFECTION – Infection is very unusual. However, viral, bacterial, and fungal infections can occur any time the integrity of the skin is compromised. Should infection occur, you must contact or return to our office immediately, as additional treatment will likely be necessary.

PIGMENT/COLOR CHANGE (hyperpigmentation) – Because the dermal penetration associated with micro-needling is so superficial it doesn’t extend into the layer of the skin containing melanocytes, hyperpigmentation is very rare. However, failure to follow post-treatment instructions can put you at risk for hyperpigmentation. You MUST avoid sun exposure for 1 to 2 weeks after a micro-needling treatment. You should also wear a daily SPF facial moisturizer, which your practitioner can recommend. Lastly, avoid picking and/or peeling the skin during healing period.
Acknowledgement

ACKNOWLEDGEMENT My signature below acknowledges that I have read and understand the content of this informed consent document. I have been given ample opportunity to ask questions, all of which have been answered in a satisfactory manner. I understand that results can vary and that no guarantee, neitherexpressed nor implied, has been or will be given to me regarding my results. I’m aware of the risks and benefits associated with the DERMA-PEN Microneedling and/ or BB GLOW TREATMENT procedure, as well as available alternative treatments. I understand that micro-needling is an elective procedure performed solely for cosmetic purposes and is not critical to my health. Of my own free will, I am requesting and providingmy informed consent to undergo DERMAPEN Micro-needling treatment(s) and/or BB GLOW TREATMENT at Glam Body Sugaring Boutique LLC. I assume all risks as my own and agree to hold harmless, Glam Body Sugaring Boutique LLC, its providers,estheticians, and any other staff members, affiliates, and independent contractors. I hereby releasethem from any liability, both seen and unforeseen, now and forever.
Today’s Date
Signature

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Glam Body Sugaring Boutique Microneedling|Nanoneedling / BB Glow Consent Form

Contraindications

Introduction to Microneedling, NanoNeedling and BB Glow

Acknowledgement