Microneedling Consent Form

Location

Date

First Name

Last Name

I confirm that the therapist has explained the treatment to me and has specifically explained to me about:

The options available to me — including having no treatment at all.

The benefits and effects of the treatments,

Post needling mandatory instructions and how to use the after-care products

I understand that I may experience

Somedegree of discomfort like burning, stinging sensation, hotness or tightness during and just after the treatment;

Imay or may not have visible redness and that each case is individual;
Thereare no guarantees as to the results of this treatment, due to many variables, such as: age, condition of skin, sun damage, smoking, climate, life style and ;
- Toachieve optimum results, I may need several treatments;
Althoughcomplications are very rare, sometimes they may occur and that prompt treatment is In case of any complications (signs of infection, scarring or pigment changes) I will immediately contact the professional who performed the treatment;
- Ishould cleanse the face gently with a soap-free cleanser, pat dry with a towel, and moisturize twice a day;

o Avoiding scratching or picking at the skin to reduce the chances of scarring;

Don'tpick off any dead/peeling skin as this may cause bleeding & discoloration, or even mild scarring.

If itching is severe during the healing phase, antihistamines may be recommended to help resolve this symptom

Itis very important that I carefully follow the advice given by the professional following the treatment to help to improve the benefit of the procedure and reduce the risk of complications or side This includes using all the homecare products as directed;

o Direct sun exposure is prohibited while I am undergoing treatment and the daily use of sunscreen with a minimum of SPF 50+ is necessary even on a dull or cloudy day;

Imust not use solariums/sun beds whilst I am undergoing treatment and during the 6 weeks following the end of

Who should not have a Micro needling?

Ifyou have a history of problems with keloid scars (raised scars that grow out beyond the original site of injury) or other types of scarring of your skin;

Ifyou have facial warts or any current facial infection;

Ifyou have used the anti-acne treatment isotretinoin (brand name Roaccutane) within the last

12 months;

If you have used steroids within the past 3 to 6 months, please consult your physician before treatment.
If you are taking blood-thinning medication (anticoagulants), please consult your physician before treatment.
If you have active cancer or have completed cancer treatment within the past 6 months, please consult your physician before treatment.

Summary of risks from Micro needling treatments:

Burningsensation and stinging;

Redness— can last for a few weeks;
Peeling— it is important that you do not pick at or peel off the skin;
- Sensitiveskin after the needling ;
Inrare cases, patients may experience an infection in the skin or an out-break of cold sores *¹
Mildtransient swelling of the face;
Hypoor Hyperpigmentation *²
Inrare cases scarring or keloids may

agreement

Client agreement I understand that the result obtained from the treatment does take time and I agree that to obtain a result, I must follow all the post-micro needling instructions explained to me by the clinician.

understand

I also understand that the result cannot be guaranteed and that there is a possibility I may have to repeat the treatment to enhance the result.

understand result

I understand that the results of the treatment cannot be guaranteed and I consent to undergo treatment having been fully informed of the benefits and possible risks of treatment.

declare

I declare that all information provided by me in this form is accurate and complete. Any omission, concealment, or incorrect information is solely my responsibility, and I release Zia Cosmetic Clinic and its staff from any liability arising from such inaccuracies.

*¹ This normally only occurs in patients who have a history of such complaints and anti-viral medication may be recommended if such complications occur.

*² Patients must use all after care products as directed and remember to use a high factor sunscreen.