MicroNeedling Consent MicroNeedling Consent Name First Last Email PhoneDOB:* MM DD YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country MicroNeedling Consent* Description: Professional skin needling system allows for controlled induction of the skin's self-repair mechanism by creating micro channels in the skin which triggers new collagen synthesis. The result is smoother, firmer and younger looking skin. Skin needling procedures are performed in a safe and precise manner with the use of sterile cartridge with a micro needle head. The procedure is normally completed within 30-60 minutes depending on the required treatment and site. Side Effects: After the procedure, the skin will be red and flushed in appearance in a similar way to moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on the area being treated. The skin's redness will diminish greatly after a few hours and within the next 24-72 hours the skin will return to a normal appearance. Contraindications: Keloid scars, history of eczema, psoriasis and other chronic conditions, history of actinic (solar keratosis, history of herpes simplex infections. Absolute contraindications include, scleroderma, collagen vascular diseases or cardiac abnormalities. Blood clotting problems, active bacterial or fungal infection, immune suppression, scars less than 6 months old. Not recommended for women who are pregnant or nursing. Client Consent: I understand that results will 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. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment, I am aware that the this professional treatment in not permanent as natural degradation will occur over time. I state that I have read (or it has been read to me) and I understand this consent and the information contained in it. If I have any questions I will contact the Esthetician about the treatment. Date Signature*PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.