You can always press Enter⏎ to continue
briefcase-health
MICRONEEDLING CONSENT
Please complete this form no later than 24 hours before your appointment.
17
Questions
START
1
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
This consent shall include treatment with any of the following modalities:
*
This field is required.
CHECK ALL BOXES TO PROCEED
Microneedling
ProCell
RF Microneedling
Previous
Next
Submit
Press
Enter
3
My main skin care concerns and the areas of focus are as follows:
*
This field is required.
Not Concerned
Somewhat Concerned
Concerned
Very Concerned
Fine Lines, Wrinkles
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Acne Scars
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Crepy, Loose Skin
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Texture/Pores
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Stretch Marks
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Hyperpigmentation
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Fine Lines, Wrinkles
Acne Scars
Crepy, Loose Skin
Texture/Pores
Stretch Marks
Hyperpigmentation
Not Concerned
Row 0, Column 0
Somewhat Concerned
Row 0, Column 1
Concerned
Row 0, Column 2
Very Concerned
Row 0, Column 3
Not Concerned
Row 1, Column 0
Somewhat Concerned
Row 1, Column 1
Concerned
Row 1, Column 2
Very Concerned
Row 1, Column 3
Not Concerned
Row 2, Column 0
Somewhat Concerned
Row 2, Column 1
Concerned
Row 2, Column 2
Very Concerned
Row 2, Column 3
Not Concerned
Row 3, Column 0
Somewhat Concerned
Row 3, Column 1
Concerned
Row 3, Column 2
Very Concerned
Row 3, Column 3
Not Concerned
Row 4, Column 0
Somewhat Concerned
Row 4, Column 1
Concerned
Row 4, Column 2
Very Concerned
Row 4, Column 3
Not Concerned
Row 5, Column 0
Somewhat Concerned
Row 5, Column 1
Concerned
Row 5, Column 2
Very Concerned
Row 5, Column 3
1
of 6
Previous
Next
Submit
Press
Enter
4
I understand the following may be contraindications, and I will notify my provider if any of the following apply to me:
*
This field is required.
(Check all that apply or indicate N/A )
Allergic reactions to stainless steel or nickel
Active infections / Acne (viral, fungal, bacterial)
Rashes, warts or skin cancer
Immune suppressed (Diabetes, Lupus, etc)
Skin related auto immune disorders (Rosacea, Eczema, etc)
Botox or Fillers 2 weeks before my appointment
Recent ablative laser treatments
Pregnancy or breast feeding
Use of blood thinners (NSAIDS, Coumadin, Warfarin)
Use of alcohol or caffeine 48 hrs before treatment
Actinic (solar) Keratosis
Keloids (scars)
Permanent facial implants
Scars less than 6 months old
History of cold sores or herpes
Heart disorders / Pacemaker
Epilepsy
Uncontrolled hypertension
Metal dental implants / retainer
None - N/A
Previous
Next
Submit
Press
Enter
5
Are you currently using, or previously used any injectable semaglutide or tirzepatide medications? (Ozempic, Mounjaro, Wegovy, Rybelsus etc)
*
This field is required.
**Use of these weight loss injections causes skin changes and inflammation which may increase chances of side effects from some aesthetic treatments. Please always notify your provider when you are using these medications. **
YES
NO
Previous
Next
Submit
Press
Enter
6
By marking YES, I affirm I have NOT used Accutane, had Chemotherapy or Radiation treatments in the last 6 months.
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
7
By marking YES, I affirm I have NOT had Botox, dermal filler, laser treatments or cosmetic surgery in the last 2 weeks.
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
8
I understand and agree photos may be taken before and after each procedure.
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
9
I understand and agree that topical lidocaine may be used by my technician for pain control. I will notify my technician if I have any allergies to anesthetics.
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
10
Microneedling may cause pinpoint bleeding and minor bruising on the skin. I understand I must discontinue the use of blood thinners , NSAIDS and vitamin supplements 1 week before treatment, and avoid alcohol and caffeine 48 hours before treatment.
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
11
I understand results vary depending on individual factors including medical history, skin type and my compliance with pre/post treatment instructions. I will require a series of treatment to achieve optimal results.
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
12
ÉCLAT Skin Confidence Spa provides a post care kit and has serums available for purchase which contain ingredients that are safe for use in my aftercare. If I elect to use my own skin care products I understand some of the ingredients may not be suitable for use with microneedling and could cause a dangerous rash or allergic reaction which may have to be medically treated.
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
13
Although complications are infrequent, I understand the following short term side effects or complications may happen to me:
*
This field is required.
(Check EACH BOX to signify you had read and agree)
My skin will become red and flushed in appearance similar to a moderate sunburn.
The skin redness may last 24-72 hours. Redness on scar revision can last longer.
I may experience tightness, itchiness, sensitivity, stinging, swelling and heat in the area being treated.
My skin may become very dry, with minor flaking, sloughing and may have pinpoint scabbing
Milia may form (white bumps) if I do not use the proper post treatment care
A flare up can occur if I have a history of cold sores
My skin can (in rare cases) get infected, if I don't follow the proper post treatment care
I may have an allergic reaction to products used in the treatment
Previous
Next
Submit
Press
Enter
14
I have received and reviewed the microneedling pre/post care instructions and agree to strictly adhere to them.
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
15
I understand the procedure, its benefits and its risks. I have been given the opportunity to ask questions, and my questions have been answered satisfactorily. I am aware there may be unforseen complications which may not have been discussed but could result from this procedure. This procedure is elective and I authorize ÉCLAT Skin Confidence Spa to perform the selected treatment(s).
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
16
I agree to contact ÉCLAT Skin Confidence Spa at 704-890-1071 immediately if any problems arise after the treatment including but not limited to rash, extended redness, pain, itching or swelling. I understand any delay in doing so could impair my result or damage my skin.
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
17
SIGNATURE:
*
This field is required.
Please provide your electronic signature below and click SUBMIT to complete. Thank you!
Clear
Previous
Next
Submit
Press
Enter
18
Signature
Please provide your electronic signature below and click SUBMIT to complete. Thank you!
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
18
See All
Go Back
Submit