BEE MICRONEEDLING CONSENT FORM

Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
Prior to receiving this treatment, I will be candid in revealing any condition that may have a bearing on this procedure. By signing below I specifically acknowledge that I have been advised of the facts and matters set below and I agree as follows:
(Please initial the line next to the number after you clearly understand each statement)
- Pregnancy/nursing
- Diabetes
- Allergies
- Use of Retin-A, Glycolic acids
- Use of Acutan
- Recent facial peels or surgery
- Tendacies to cold sores
- Botox (within 14 days)
- Fillers (within 14 days)
- Hormonal therapy
Microneedling may not be used on any of the below conditions. Please disclose any of these health or medical issues.
- Open sores or lesions
- History of skin cancer
- Active acne
- Eczema
- Any stage of melanoma
- Broken or irritated skin, including conditions such as hives or dermatitis
- Rosacea
- Raised surfaces on skin (moles and etc.)
- Any type of skin infection
- I understand there are no guarantees to this procedure.
- I understand there may be some degree of minor discomfort (scratchiness, itchiness and bruising).
- I understand that to achieve maximum results, I will need several ongoing treatments and will need to use daily products to heal and protect my skin.
- I understand that the possibility of irritation and redness exists and that I should notify my skin care professional if irritation persists
- I will follow the home care program specifically designed for me without changing or adding any products without consulting with my skin care professional.
- I agree to all of the above to have this treatment performed on me and will follow all prescribed directions regarding post treatment care.
- I understand that Microneedling will be used to treat skin tightening, acne scarring, wrinkles or lift/firm the skin.
- I understand that most clients look as though they have a moderate to severe sunburn and my skin may feel warm and tighter than usual. Most clients usually recover within 24 hours or less, but sometimes redness may persist for several days. Because the device may penetrate the skin there can be risk of infection. If this occurs, a follow up appointment will be required for further treatment.
- I grant permission to Bee Waxed Cosmetics to reproduce the photographs taken of me. for the purpose of publication on web or any and all promotion, illustration, advertising, or trade, in any manner or in any medium.
PLEASE READ: IF YOU HAVE ANY OF THE FOLLOWING CONDITIONS INFORM OUR SKINCARE PROFESSIONAL YOU MAY NOT BE A QUALIFIED CANDIDATE FOR MICRONEEDLING
- Contraindications to Treatment Contraindications and precautions include: keloid or raised scarring; history of eczema, psoriasis, actinic (solar) keratosis, herpes simplex infections, diabetes, and other chronic conditions; presence of raised moles, warts or any raised lesions in the target area. Absolute contraindications include: scleroderma, collagen vascular diseases or cardiac abnormalities; rosacea or blood clotting problems; active bacterial or fungal infections; immuno-suppression; scars less than 6 months old; and facial fillers used in the past 2 - 4 weeks. Treatment is not recommended for patients who are pregnant or nursing.
- Client Consent: I understand that results will vary between individuals. I also understand that although I may see a change after my first treatment, I may require a series of sessions to obtain my desired outcome. The procedure and side effects have been explained to me, including alternative methods. I understand the advantages and disadvantages of this procedure
- I am advised: though good results are expected, the possibility and nature of complications cannot be accurately advised; therefore, there can be no guarantee as expressed or implied either to the success or other result of the treatment. I am aware that micro-needling treatment is not permanent and natural degradation will occur over time.
- I agree that I have read and understand this consent form, and that I understand the information contained in it.
I have read and understand the contents of each statement above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself. The above points of information have been specifically discussed and made clear and I have had the opportunity to ask any questions concerning this information. I now authorize ¬Bee Waxed Cosmetics to begin my treatment with Microneedling
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