The following points of information, among others, have been specifically discussed and made clear and I have had the opportunity to
ask any questions concerning this information:

,(patients name) understand that MICRO-NEEDLING will be used today to treat
.
I have been examined by my provider and have been cleared for this procedure.

Initials:
2. Any and all follow-up treatment (if necessary) needs to be scheduled with a licensed medical provider to determine if
additional treatments are necessary.

Initials:
3. I understand that most patients look as though they have a moderate to severe sunburn and my skin may feel warm and
tighter than usual. Most patients usually recover within 24 hours or less. Because the device may penetrate the skin there
can be a risk of infection, if this occurs, a follow up appointment will be required for further treatment.

Initials:
4. Micro-needling may not be used directly on any of the below conditions. I have disclosed any of the health concerns below
that apply to me:
Open sores or lesions
Skin cancer
Broken or irritated skin, including conditions such as hives or dermatitis
Any stage of melanoma
Rosacea (Nodule)
Raised Surface
Eczema
Active Acne
Any type of skin infections

Initials:

Client Name (printed)

Client Name (Signature)