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).

PATIENT INFORMATION

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?
Have you taken aspirin or blood thinners in the past 2 days?
Do you have an allergy to Aloe Vera?
Have you taken any mood altering drugs in the past 48 hours?
I consent and authorize the use of any photographs of me for the purposes of marketing and education
If no, may we blur out your face and/or tattoos and use the photos that way?
Are you sensitive to Latex?
Do you have trouble healing?
Are you currently undergoing radiation or chemotherapy
Are you currently using Accutane, Retin-A, AHA, or other exfoliating skin care
Are you currently taking anti-inflammatory medications or steroids?
Do you have a history of skin disease?
Do you have a history of skin sensitivity?
Are you currently taking vitamin A or E in any form?
Are you pregnant or nursing?
Please check any that apply to you:

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