Micro Channel Consent Form | Naked Face Spa LLC

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MICROCHANNELING CONSENT FORM

MicroChanneling is an elective procedure for cosmetic purposes only. I have had the opportunity to ask questions and understand the nature, goals, limitations and possible complications of this treatment. I have had the opportunity to discuss alternative forms of treatment and understand that results may vary.

CONTRAINDICATIONS

While MicroChanneling treatments are safe and effective for most women and men, there are some people who will not be good candidates for treatments, Here is a general contraindication

• Pregnancy — if you are pregnant or nursing you are advised to not receive any MicroChanneling treatments. To date there have been no studies conducted to see what effects these treatments may have on the unborn child, but as a general rule pregnant women should stay away from any type of cosmetic/elective procedures.

• Diabetes - unstable diabetes patients should not be treated due to healing problems.

• Active Herpes Simplex in the treatment area - treatment is possible once the outbreak is healed, however it may be advisable to take prescription strength antiviral medication to keep this condition in remission during the treatment series

• Dry skin - if your skin is overly dry, you will need to start moisturizing and ensure the condition is under control prior to undergoing any treatment.

•Any active inflammatory skin condition e.g. eczema, psoriasis, infection, rash or any type of dermatitis at the treatment site (because it may aggravate the condition).

I have no allergies to anything that I am aware of.

I understand that I must verbally inform my technician of any concerns, use of medication (including pain medications) and medical conditions I have before receiving MicroChanneling.

I am not under the influence of alcohol, drugs or any other substances.

I release ProCell Therapies, and its subsidiaries and representatives of all claims for injury seen or unseen that may occur as a result of this procedure.

I understand that no promise has been made to me as to the final result of the procedure.

I have been given the opportunity to address all of my questions and concerns about the risks, hazards and aftercare for the procedure(s) that will be performed with my consent.

I hereby release ProCell Therapies from liability associated with my Microchanneling treatment.

Name

Phone

Email

Your Signature

Date

PATIENT INFORMATION

Name

Date

Address

City ,State , ZIP :

Phone

Email

How did you hear about us?

Microchanneling is an elective procedure for cosmetic purposes only, I have had the opportunity to ask questions and understand the nature, goals. limitations and possible complications of this treatment. I have had the opportunity to disci. alternative forms of treatment and understand that results may vary.

CONTRAINDICATIONS

While Microchanneling treatments are safe and effective for most women and men, there are some people who will not be go candidates for treatments. Here is a general contraindication:

• Pregnancy - if you are pregnant or nursing you are advised to not receive any Microchanneling treatments. To date there have been no studies conducted to see what effects these treatments may have on the unborn child, but as a general rule pregnant women should stay away from any type of cosmetic/elective procedures.

• Diabetes - unstable diabetes patients should not be treated due to healing problems.

• Active Herpes Simplex in the treatment area - treatment is possible once the outbreak is healed, however it may advisable to take prescription strength antiviral medication to keep this condition in remission during the treatment series_

• Dry skin - if your skin is overly dry. you will need to start moisturizing and ensure the condition is under control prior to undergoing any treatment.

• Any active inflammatory skin condition e.g. eczema. psoriasis, infection, rash or any type of dermatitis at the treatments (because it may aggravate the condition).

Are you over 18 years of age?

Yes

No

Have you taken aspirin or blood thinners in the past 2 days?

Yes

No

Do you have an allergy to Aloe Vera?

Yes

No

Have you taken any mood altering drugs in the past 48 hours?

Yes

No

I understand that if I have a history of cold sores, herpes or fever blisters I must take my medication prescribed by my physician in advance or tell the technician to skip treatment around my lips.

Your Signature

I authorize __________________ to perform Microchanneling on my skin, and to apply topical preparations as determined necessary. I understand that Microchanneling is non-ablative skin rejuvenation & involves the creation of perforation in my skin to promote healing responses to rejuvenate my skin.

I understand that the procedure is performed with an automatic perforating device and that clinical results may vary. I understand there is a possibility of short-term effects such as reddening, peeling, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as infection & scarring. These effects have been fully explained to me. Clinical results may vary depending on individual factors, including medical history, amount of sun damage or textural problems, skin type, and my compliance with pre/post treatment instructions.

I understand that the Kcrochanneling treatment may involve a series of treatments and the fee structure has been fully explained to me. I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and 1 understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I confirm that l am not pregnant at this time. I also have completed a medical history checklist and been informed about what I must do and not do'' before, during and after the procedure. I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedures.

I consent and authorize the use of any photographs of me for the purposes of marketing and education

Yes

No

If no, may we blur out your face and/or tattoos and use the photos that way?

Yes

No

I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents: of this consent form. I furthermore indemnify the authorized person herein, and hold harmless from any and all claims, demands, liability judgments, costs and expenses arising out of any claims relating to the procedure authorized herein.

Are you sensitive to Latex?

Yes

No

Have you had a chemical or LASER peel? If so, when?

Do you have trouble healing?

Yes

No

Have you had any botox or fillers? If so, when?

Are you currently undergoing radiation or chemotherapy

Yes

No

Are you currently using Accutane, Retin-A, AHA, or other exfoliating skin care

Yes

No

Are you allergic to any metals? If so, what?

Are you currently taking anti-inflammatory medications or steroids?

Yes

No

Are you allergic to any anesthetics, (any of the "caines")? If so, which?

Do you have a history of skin disease?

Yes

No

Do you have a history of skin sensitivity?

Yes

No

Are you currently taking vitamin A or E in any form?

Yes

No

Are you pregnant or nursing?

Yes

No

Are you currently being treated by a dermatologist? If yes, what for?

Derm Name

Please check any that apply to you:

Heart Condition

Hyper Pigment

Accutane in last 5 yrs

Hepatitis

Smoker

HIkeloid Above Neck

Diabetes (uncontrolled)

Chronic Skin Disease

Cold Sores

Allergic to Steel

Initial

Date

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Naked Face Cosmetic Spa is devoted to awakening a fresh perspective towards the external appearance and illuminating the beauty of bare skin through the intentional and skillful use of industry leading skincare & cosmetic treatments.

Founded by Haley Blanding.

Full body and Face Tattooing, Permanent Makeup, Medical and Restorative Tattooing, Tattoo Removal, Piercings &

Spa Spa Services

Spa Location: 10025 Lakewood Drive SW, STE B Lakewood, WA 98499

Tattoo Location: 11120 Gravelly Lake Drive SW STE 10

Lakewood, WA 98499

© 2022 Naked Face Spa Cosmetic. | Establishes in 2018

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