Microneedling Consent Form

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The nature and purpose of this treatment has been explained to me and any questions I have regarding the treatment have been answered to my satisfaction.

I agree to allow pictures to be taken and shared of me.

I understand there are no refunds on services rendered.

I understand that if I choose to reschedule or cancel my appointment I must give a 48hr notice or I will be charged the full price of the service not including any discounts or specials.

I understand that the treatment may involve the risk of complication or injury and I freely assume those risks. Possible side effects of the treatment area can include mild redness of the skin, irritation and dryness.

If a microneedling or other treatment is apart of this treatment I understand that the sensation and penetration of the treatment will be enhanced. Which may cause skin irritation, mild discomfort, and tenderness, lightening or darkening of the skin, infection, scarring, peeling, and activation of cold sores.

I certify that I have read this entire consent and that I understand and agree to the information provided in this form. I certify that I am competent adult of at least 18 years of age, or that, if I am a minor under the age of 18, I understand that the consent of my parent/guardian having legal custody will also be required before treatment. This agreement will remain in effect for this procedure and all future procedures conducted by Adore. I have read and fully understand all information in this agreement.

Please list all current medications:

Please list all current allergies:

Please list all surgeries:

Other:

Do you have the tendency to keloid scar on the face?

Do you currently have an active bacterial, fungal, or viral skin infection on the face, including herpes simplex (cold sore)?

If yes, the procedure will be rescheduled. Unless you are and have been pretreating.

Have you used Accutane in the last six months?

Have you had Botox and/or Juvederm or any other filler in the last two weeks?

Have you had any waxing of your brows, upper lip or face in the last 72 hours?

What is your major reason for being here today?

What skin type and/or problem do you feel you have?

Have you ever had a facial treatment before? If yes, where and when? Was it a beneficial experience?

Have you ever had a reaction to a food, cosmetic, or skin care product? If yes, please give details:

Where do you purchase most of your face and body care products?

How much time do you spend on your daily skin care/make-up routine?

How you feel about your skin conditions? What would you like to improve?

Do you tend to tan or burn?

Do you smoke or drink? How often?

Do you exercise and how often?

How much sleep do you get per night?

Are you interested in long or short term spa treatment?

Are you pleased with your current products?

I agree and adhere to all safety precautions and regulations during the skin treatment. I have received and understand the post care recommendations as follows: no sun exposure for 48 hours, moisturize as needed and use gentle cleanser only. Use of sunscreen is highly recommended post-treatment for at least next 7 days. (SPF 30)

Client Signature

Date

Client Signature (copy)

Asthetician Signature

Date

Parent or Guardian Consent (Required for Minors):

I GIVE MY PERMISSION AS

Parent
Guardain

of:

Name

First

Last

for this service.

I have read and fully understand and accept this Informed Consent/Release of Liability Form and agree to accept all of the provisions and certify that the information collected is true.

Layout

Parent Signature:

Date

402 669 7094

By Appointment Only

4935 S 136th St, Omaha, NE, 68137

Microneedling Consent Form

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