Skin Needling Consent form

Date(Required)

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Phone(Required)

Email(Required)

Your Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Occupation

How did you hear about us?(Required)

Would you like to be informed of our specials?(Required)

(Please ensure you have clearly supplied your email id & contact no. above)

Yes

I confirm that I am over 18 years old.(Required)

I confirm that I am over 18 years old.

Initial(Required)

I consent to the Micro-Needling treatment as carried out by 1st Lady Health & Beauty being performed on me.

Initial(Required)

I understand that I will require multiple treatments to obtain optimum results.

Initial(Required)

I am aware that the practices of cosmetic medicine and skin therapies are not an exact science and that the result cannot be guaranteed. No such guarantee as to the result of this treatment has been given to me.

Initial(Required)

I approve and consent for my technician (if required) to apply the Topical Anesthetic Cream as my career prior to the Skin Needling Treatment being carried out on me.

Initial(Required)

I approve and consent for my technician (if required) to apply the Topical Anesthetic Cream as my career prior to the Skin Needling Treatment being carried out on me.

Initial(Required)

I confirm that I have done the following:

• I have advised my technician of any current Medication.
• I have advised my technician of my genetic heritage
• I have advised my technician of all the treatments and products used on the area to be treated within the last 7 days.
• I confirm I have not applied topical prescription retinol to the treatment area in the last two weeks.
• I confirm I have not applied a cosmeceutical retinol to the treatment area in the last 12 hours.

Initial

For darker skin types, prior to the micro-needling treatment, I will have prepped my skin for a minimum of 2 weeks with an active cleanser, pigment inhibitor, vitamin A and broad-spectrum SPF 50+

Contra-Indications

Initial(Required)

I confirm that none of the following contra-indications apply to me:

• Allergies to Topical Anesthetic
• Sunburn, sun exposure, sunbed within the last 24 hours
• Isotretinoin within the last 6 months
• Cosmeceutical retinol within the last 12 hours (in the treatment area)
• Laser or IPL hair reduction, waxing within last 1-2 weeks
• Depilatory cream within last week (in the treatment area)
• Eczema or Psoriasis or active lesions (in the treatment area)
• Fungal Dermatitis
• Active cold sore on the are to be treated
• History of abnormal or keloid scarring
• Chemical or radiation therapy
• Anti-wrinkle treatment within the last 48 hours
• Dermal fillers within the last 4 weeks

After Care Instructions

Initial(Required)

I understand that for a minimum of 24hrs after treatment I should:

• Keep cool, Keep hydrated, and increase water intake to 8 glasses per day
• Avoid sun, steam, sauna, and spa.
• Avoid exercise and swimming.
• Avoid any activities that would cause excessive perspiration

Initial(Required)

I understand that for 3 days after treatment I should:

• Use gentle products only
• Apply a soothing lotion and broad-spectrum SPF 50+ daily

Initial(Required)

I understand that after treatment I should:

• Avoid any exfoliation on the treated area for the next 2 weeks.
• Avoid sun exposure for 2 weeks

Initial(Required)

I understand that failure to follow these important instructions may lead to an adverse outcome from this treatment.

Initial(Required)

I have been explained with pre- and post-care information for Micro-Needling treatment

Potential Risks and Outcomes

Initial(Required)

I confirm that I understand the following are potential risks or outcomes from this treatment:

Minor flaking, dryness, and peeling which may last several days
Residual, temporary redness to the skin
Temporary swelling and tenderness
Petechiae may occur
Skin discoloration can occur, hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin)
Development of infection that in rare cases could lead to scarring (extremely rare and caused by picking, and failure to follow aftercare instruction)
If prone to cold sores the treatment may trigger a breakout, antiviral medication is advised for 1 week prior to the treatment to minimize this risk

Initial(Required)

I confirm that the nature of treatment and the risk involved have been explained to me.

Initial(Required)

I have had any questions answered to my satisfaction and read all the written information on this form.

Photo release consent

Initial(Required)

I acknowledge and consent to photographs being taken of me before and after this treatment and that these photographs will form part of my medical records held by the 1st Lady Health & Beauty and will be used in accordance with 1st Lady Health & Beauty’s Privacy Policy.

The photographs (please tick where relevant)(Required)

It May be used for the 1st Lady Health & Beauty meeting and internal staff training

It May be published, in whole or in part may be edited, for ‘1st Lady Health & Beauty’ publicity including all forms of advertising. In this instance, I acknowledge and agree that the use of the image does not infringe my moral rights, or breach my privacy or confidentiality.

Consent and Acknowledgment:

Initial(Required)

I confirm that the answers I have provided in this consent form are true and correct and understand that 1st Lady Health & Beauty has relied on these answers in agreeing to perform the Skin Needling treatment on me. I have disclosed all relevant information regarding my medical history and medical condition. If anything in my medical condition has changed since my last visit, I agree that it is my responsibility to advise and update 1st Lady Health & Beauty.

Initial(Required)

I am aware and acknowledge that undertaking Skin Needling treatment may carry the risk of causing harm or damage to my health and safety. If I have disclosed any illness or condition that 1st Lady Health & Beauty considers may pose a risk, I understand that 1st Lady Health & Beauty may, in its absolute direction, refuse to provide Skin Needling treatment to me until such time that I provide medical clearance satisfactory to 1st Lady Health & Beauty.

Initial(Required)

I voluntarily have sought to have the Skin needling treatment performed on me and I assume all risks associated with participation in such treatment. By proceeding with the Skin Needling treatment, I agree that I am personally and unconditionally assuming responsibility for any harm, loss or damage suffered by me because of the treatment.

Initial(Required)

I unconditionally release, discharge, and indemnify 1st Lady Health & Beauty and of their respective director, officers, employees, agents, contractors, and related entities against any claim, allegations, demands, action, or cause of action arising out of, or related to, having the Skin Needling treatment performed on me.

Client Signature(Required)

Specialist Signature(Required)

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