Microneedling | Rammy Rose

Microneedling: Online Consent Form

Please fill out the following form.

First name

Last name

Email

Phone

Date of birth

Year

Month

Day

Age

Please check all current and previous medical conditions listed below that apply to you

Are you being treated for any other conditions not listed above?

Yes

No

Are you currently using Retinol Cream or Accutane?

Yes

No

Are you using any products that contain AHA's or Glycolic acids

Yes

No

Have you had any facial piercings or tattoos?

Yes

No

Have you had any botox or fillers within the last 4 months?

Yes

No

Have you had any tanning services within the last 3 months?

Yes

No

Have you had any severe facial sun burns within the last year?

Yes

No

Possible Side Effects and Contraindications:

After the procedure, the skin will be red and flushed in appearance similar to a moderate sunburn. You will experience the feeling of tightness and possibly a mild irritation to the skin afterwards that will diminish greatly over the next few hours. It is not common but occasionally mild bruising can occur depending on the depth the needles are being used at and the clients skin. Peeling and dry skin is common for up to a week afterwards as skin cells are turning over and new ones are resurfacing. Very rarely clients will experience minimal scabbing.

I understand the following contraindications below may result in my service being denied and will notify my provider if any of the following applies to me:

Active Infections - viral, fungal, bacterial
Rashes on the treatment area
Skin Cancer
Active Acne or Rosacea
Skin related autoimmune disorders
Clients on blood thinners both prescribed and over the counter
Recent ablative dermal procedure
Pregnant or breastfeeding

Please checl each box after understanding the below statments:

I understand that results may vary between individuals. I 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 its side effects have been explained to me. I understand the benefits and disadvantages of this procedures

I am advised that although good results are expected, the possibility and nature of complications cannot be accurately advised and there can be no guarantee expressed or implied to the success of the treatment

I am aware that the microneedling treatment is not permanent and that natural degradation will occur over time

I agree that I have read (or it has been read to me), and I understand this consent form and the information contained in it

I have had the opportunity to ask any questions about the treatment, including risks, and I acknowledge that all of my questions about the procedure have been answered to my satisfaction

The treatment fees have been discussed with me and I understand them. We require a 24 hour notice if cancellations or a 50% treatment cost will be charged

The treatment fees have been discussed with me and I understand them. We require a 24 hour notice if cancellations or a 50% treatment cost will be charged

THIS AGREEMENT AFFECTS YOUR LEGAL RIGHTS, READ IT CAREFULLY

I confirm the answers I have given in this form are correct, and I have not withheld any information requested by this form
I have been informed of the proper use of equipment for the services I am receiving
I have been advised of all risks associated with the use of equipment required for the services I am receiving. I have been advised of all the risks associated with the services and procedures I will be receiving. I agree to comply with all instructions provided by the operator
I hereby release Rammy Rose Hair & Beauty Ltd its affiliates, officers, directors, agents, employees and contractors from liability for any injury, loss or damage that may result from my use of equipment or from any services provided or treatment rendered. This release binds my heirs, successors and assigns

Signature

Date picker

I declare that the info I’ve provided is accurate and complete.

Please show your filled form to the service provider, without their acknowledgement, this form cannot be submitted, and we will not start the service until the form is submitted

Service Provider Signature

I have checked the client’s form for any contraindications and have consulted with the client what the effects of these contraindications will have during and after the service