Microneedling/NanoInfusion Consent Form

Nanoinfusion Consent Form

First Name

Last Name

Please check each box after reading the segments Required

I acknowledge I have NOT used Accutane or any medication for the same purpose during the last 6 months.

I acknowledge that if I have ever had a cold sore or fever blister, I have informed the specialist and should consider taking an anti-viral medication to help avoid a possible breakout. The medication should be used 2 days prior and 2 days after any aggressive facial exfoliation treatment.

I acknowledge that there is NO GUARANTEE that dark discoloration of skin will be reduced or fade. Pigmentation or lines may improve with a series of treatment. Pigmentation may darken. I acknowledge the need for proper skin care regimen.

I acknowledge my skin may experience temporary irritation, tightness and redness. I am aware that I need to wear SPF30 otherwise I am more susceptible to sunburn, skin damage and hyperpigmentation.

I acknowledge that this treatment is strictly an elective skincare treatment and NO medical claims have been expressed or implied. Although the results are usually dramatic, I have been informed that there is no guarantee of results. To achieve the most benefit and result, I understand 4-6 treatments are necessary with 2-4 weeks between each service.

Please make sure to confirm your appointment in your text/email message. Any appointment that is not confirmed within 24 hrs will be cancelled. If you are more than 15 mins late to your appointment, we will try to accommodate your service, however, we may have to shorten the duration to end on time and you will be charged the full service amount or you may be asked to reschedule if we can't accommodate you. No-call/No-show: to be able to rebook with us, we will charge your card 50% of the service amount which is a non-refundable booking fee. Once your service is completed, that amount will go toward your total and you will need to pay the balance. If you no-call/no-show, you forfeit your booking fee.

Signature

Date

I declare that the info I’ve provided is accurate & complete

Thank you for submitting! We will see you at your appointment!

​

Nanoinfusion Consent Form