Rejuvapen Consent Form

110 Fairview Ave. Suite 3 Verona NJ, 07044

    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)