Microneedling Waiver - Shape it Up Contouring

Consent to Treatment Form Microneedling

Please read before proceeding

I understand that Microchanneling/Microneedling is non-ablative skin rejuvenation & involves the creation of
perforations in my skin to promote healing responses to rejuvenate my skin. I understand that the procedure is performed with an automatic perforating device and that clinical results may vary. I understand there is a possibility of short-term effects such as reddening, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as infection & scarring.

These effects have been fully explained to me.

Clinical results may vary depending on individual factors, including medical history, amount of sun damage or textural problems, skin type, and my compliance with pre/post treatment instructions.

I understand that the Microchanneling treatment may involve a series of treatments and the fee structure has been fully explained to me.

I certify that I have been fully informed of the nature and purpose of the procedure, expected
outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.

I confirm that I am not pregnant at this time. I also have completed a medical history checklist
and been informed about what I must do and "not do" before, during and after the procedure.

I consent to the taking of photographs and authorize their anonymous use for the purposes of clinical audit, education and promotion.

I certify that I have been given the opportunity to ask questions and that I have read and fully
understand the contents of this consent form.

I furthermore indemnify the authorized person herein, and hold harmless from any and all
claims, demands, liabilities, judgments, costs and expenses arising out of any claims relating
to the procedure authorized herein.

Signature

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Are you are currently taking any medications or supplements?

Yes

If yes, please list.

Do you have any specific skin care problems / allergies pertaining to your face or body?

Yes

If yes, please list.

Have you ever had chemical peel, laser, microdermabrasion, or any skin resurfacing treatments?

Yes

Client Name

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Client Signature

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(951) 635-6304

Consent to Treatment Form Microneedling

Please Read each and Click to check that you fully understand.

Murrieta Body Contouring
(951) 635-6304

(951) 635-6304

Consent to Treatment Form Microneedling

Please Read each and Click to check that you fully understand.

Murrieta Body Contouring(951) 635-6304

Murrieta Body Contouring
(951) 635-6304