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My Account
Cart
0
About
Services
Facials
Resurfacing Peels
Microneedling
Hydra-Infusion
Waxing
Sugaring Hair Removal
Add-Ons
Skin Classic
LED Therapy
Specials
Shop
Testimonials
Contact
Book Now
Consent for Treatment
For Collagen Induction Therapy/Micro-Needling
Name
*
First Name
Last Name
I hereby give my consent to undergo Collagen Induction Therapy (Micro-needling) treatments provided by licensed professional.
I understand this technique involves the introduction of fine needles through the skin. The purpose is to create micro-channels in the skin allowing the infusion of active ingredients (such growth factors and hyaluronic acid) to penetrate deeply and effectively into the dermis, nourishing the skin and stimulating the regrowth of collagen. A series of 3 to 6 treatments are recommended and the frequency will depend on the intensity and depth of the needle.
I understand that the treatments require many small injections on the area(s) to be treated. I understand that the administration of numbing creams may be used if deemed needed.
Micro-needling is not suitable in these circumstances:
⬥ Have used Accutane (isotretinoin) within the last year. ⬥ Have open wounds, cuts or abrasions on the skin ⬥ Have had radiation treatment to the skin within the last year ⬥ Have any kind of current skin infection, condition, herpes simplex in the area to be treated ⬥ Are pregnant or breastfeeding ⬥ Have any history of keloid or hypertrophic scars or poor wound healing
I understand that there are some risks with any procedure. The following are possible reactions with Micro-needling: temporary bruising, skin discomfort during injections, redness or swelling, lightening or darkening of the skin, itching and burning. Skin infection is a possibility any time an injection or surgical procedure is done. Side effects are most of the time temporary and typically resolve within 3 days. Total healing time depends on the depth of the treatment, skin type, and skin condition, and some patients may heal completely in 24 hours.
By my signature, I certify that I have thoroughly read and understand the contents of this form and the disclosures listed above were made to me. I acknowledge that no promises or guarantees have been made to me as a result of the treatment.
I am aware that the results achieved by this treatment may vary from person to person. Some patients typically notice an immediate glow, but visible improvement will take about 2-4 weeks and can continue for up to 6 months.
I have read potential risks have been explained to me and I accept them.
I hereby give my voluntary consent to have this treatment performed on me.
Patient Signature
*
First Name
Last Name
Date of Signature
*
MM
DD
YYYY
Please indicate areas of concern:
*
(See image below for reference.)
Forehead
Frown Lines
Freckles & Pigmentation
Crow's Feet
Dark Circles
Blood Vessels
Nasolabial Folds (Nose-to-Mouth Lines)
Scarring
Vertical Lip Lines (Smoker's Lines)
Oral Commisures (Corner of the Mouth Lines)
Lips: Definition and/or Fullness
Marionette Lines (Mouth-to-Chin Lines)
Larger Pores, Poor Skin Texture & Fine Lines
Thank you!
