Consent Form

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Skin Needling & Factor Q3 Consultation & Consent Form

Skin needling system allows controlled induction of the skins self-repair mechanism by creating micro “injuries”. This then triggers new collagen
synthesis yet does not pose the risk of permanent scarring. After multiple treatments, this will induce new collagen. Micro needling conjunction with
FactorQ3 provides optimal healing and results.

Title

Mr. Mrs Miss Ms

Name:

Date:

Adderss:

Phone:

E-mail:

DOB:

Emergency Contact:

Please list all medications that you take regularly, including hormones, vitamins, etc.:

Areas of concern:

Allergies:

Are you currently under doctors’ care?

Yes No

Details

Do you smoke?

Yes No

If so, how many per day?

Are you on HRT? (Hormone replacement therapy)

Yes No

Have you had (in area of treatment):

Chemical Peel Dermabrasion Laser Surgery

Other

Do you have permanent makeup/implants or injectables (Filler/Botox) in treatment area?

Yes No

Details:

Have got ANY type of skin tan (fake or natural/sun exposure)?

Yes No

Details:

How did you hear about us?

Client Treament Report

Date of Treatment

Clinician Name

Clinician Signature

Treatment Area

Settings Used

Amount Paid

Payment Details

Comments

Home Care Regime

Cleanser:

Eyes:

Serum:

Moisturiser:

SPF

Cleanser:

Eyes:

Serum:

Moisturiser:

Medical Informed Consent

I consent and authorise________________________________ to perform hydrodermabrasion treatment on me. I understand the following points and have had the opportunity to ask questions during my consultation.

In relation to my initial and all subsequent treatments I advise that: (Please tick)

Treatment is successful on most clients but my individual results cannot be guaranteed.
Most clients require 6 – 10 treatments to achieve results, some may require more. Individual results depend on many factors; thus, it is extremely difficult to advise on exact number of treatments required.
Exposure to UV Rays will compromise my treatment, therefore I will use SPF 30+ sunscreen.
ot following the program regarding timing of treatments and after care advice will reduce/affect efficacy of my treatment

Risks associated with treatment: Even though the risk of Hydrodermabrasion complication is extremely low, the following can occur: (Please tick)

Potential risk including grazing crusting, itching, pain, bruising, pimple-like bumps, dry skin, hypopigmentation (lightening of the skin), hyperpigmentation (darkening of the skin), blistering, burns, infection, scabbing, swelling, a very small risk of scarring and a failure to achieve the desired result. Allergic or delayed inflammatory reactions can develop. I consent to photographs taken to evaluate effectiveness. Photographs revealing my identity will not be used without consent. I am aged 18 years or over (otherwise parent or guardian to sign). I will advise (salon) of any changes that occur during my treatment that can increase potential risks or reduce efficacy. I also understand that there will be no refund for any performed services.

In relation to my initial and all subsequent treatments I advise that: (Please tick)

I have read all of the above and had all my questions satisfactorily answered. Note: Do not sign this form until you have read and understood all of the above.

Client Full Name(Please print name)

Client Signature

Date

Parent/Guardian Full Name (Please print name) *Under 18 years of age requires parental consent

Parent/Guardian Signature

Date

Trainer’s Full Name (witness) (Please print name)

Trainer’s Signature

Date

Pre & Post Care Information Sheet
(Client Copy)

Pre-Skin Needling Treatment Recommendations

No sun exposure 2 weeks prior treatment
Discontinue use of active products 72 hours prior treatment
Skin prepped on Tyrosinase inhibitor, Vitamin A, B and C 4 weeks prior the skin
No exfoliation 72 hours prior treatment
No waxing, hair removal treatments 72 hours prior treatment
No active herpes simplex, prep 72 hours prior treatment
Use of a physical sunblock

Post Needling Treatment Recommendations (Hair Removal)

Do not wash the treatment area for the following 12 hours
Avoid Physical activity, hot showers and saunas for the next 48 hours
Avoid sun exposure 72 hours post treatment
Avoid spray and self-tanning in the area of 72 hours
Avoid intensive cardio, exercise or gymnasium regimens for 72 hours
Avoid active products of 5 – 7 days
Light mineral make-up can be applied after the next 72 – 96 hours
Zinc physical sunblock is mandatory 24 hours post treatment
Drink plenty of water for hydration
Wash hands before touching or rubbing the treated area
Refrain from shaving/waxing the treated area for 72 hours

For any questions, concerns or booking please contact our salon on ………………………………………….…

In the event of an emergency, contact our senior clinician directly on …………………………………………… or your local doctor.

Consent Form

Schedule Your Visit Today

Skin Needling & Factor Q3 Consultation & Consent Form

Client Treament Report

Home Care Regime

Medical Informed Consent

Pre & Post Care Information Sheet(Client Copy)

Pre-Skin Needling Treatment Recommendations

Post Needling Treatment Recommendations (Hair Removal)

schedule A Visit

Pre & Post Care Information Sheet
(Client Copy)