• PROCELL THERAPIES MICRO-CHANNELING CLIENT CONSENT FORM

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  • Are you over the age of 18?
  • Do you take aspirin or blood thinners regularly?
  • Have you had injectables in the past 30 days?
  • Have you taken any mood altering drugs in the past 8 hours?
  • Do you have a history of cold sores, herpes, or fever blisters?
  • Are you allergic or sensitive to Latex?
  • Do you have any allergies or sensitivities? If so indicate below

  • Have you had a chemical peel or LASER peel? If so when was your last treatment?

  • Do you have trouble healing?
  • Are you currently undergoing radiation or chemotherapy? Please indicate last treatment

  • Are you currently using Retina-A, AHA, or other exfoliating skin care products?
  • Are you allergic to any metals?
  • Are you currently anti-inflammatory medications or steroids?
  • Are you allergic to any anesthetics (any of the "caines") ?
  • Do you have a history of skin disease?
  • Do you have a history of skin sensitivity?
  • Do you have a history of skin sensitivity? If so explain

  • Are you currently taking Vitamin A or E in any form?

  • Are you pregnant or nursing?

  • Are you currently being treated by a dermatologist?

  • Please mark any that pertain to you

  • I understand that Microchanneling is non-ablative skin rejuvenation & involves the creation of perforations in my skin to promote healing responses to rejuvenate my skin. I understand that the procedure is performed with an automatic perforating device and that clinical results may vary. I understand there is a possibility of short-term effects such as reddening, peeling, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as infection & scarring. These effects have been fully explained to me. Clinical results may vary depending on individual factors, including medical history, amount of sun damage or textural problems, skin type, and my compliance with pre/post treatment instructions.

    Iunderstand that the Microchanneling treatment may involve a series of treatments and that the fee structure has been fully explained to me. I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained, and that there are no refunds offered for lack of satisfactory results. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I confirm that I am not pregnant at this time. I also have completed a medical history checklist and been informed about what I must do and "not do" before, during and after the procedure. I consent to the taking of photographs and authorize their anonymous use for the purposes of clinical audit, education and promotion. I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.

    I furthermore indemnify the authorized person herein, and hold harmless from any and all claims, demands, liabilities, judgments, costs and expenses arising out of any claims relating to the procedure authorized herein.

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