Radio Frequency Skin Needling Consent Form

RF SKIN NEEDLING CONSULTATION

AND CONSENT FORM

Please answer the consultation questions appropriately. This questionnaire will guide us for your upcoming treatment.

Full Name *

Phone *

Email *

Date of birth *

Medical History

Do you have any allergies? If yes, please specify: *

Are you currently taking any medication? *

Yes

Do you have any history of skin diseases, disorders, or issues? If yes, please specify: *

Are you currently pregnant or nursing? *

Yes

Do you have a history of keloid scarring? *

Yes

Consent and Acknowledgment

In relation to my skin needling treatment, I have been advised as follows:

Treatment is successful on most clients, but my individual results cannot be guaranteed. Most clients require 3 – 6 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. Result might not be present until 3 – 6 months after having course recommendation. - -
Darker skin type clients will require additional treatments due to low intensity application. -
No UV exposure for 24 – 48 hours, the use of SPF 30+ is mandatory. Not following the program regarding timing of treatments and after care advice will reduce/affect efficacy of my treat
I am 18 years or over.-
I understand that there is no refund for any of the services performed.I am fully aware that this procedure is made voluntarily, and I have had the opportunity to ask questions and have them answered to my satisfaction.
I have been informed about the aftercare instructions and commit to following them diligently.
I release the practitioner and the establishment from liability if any complications or unfavourable results arise from the treatment.
I understand the costs associated with this procedure and accept full responsibility for these costs.
I certify that I have voluntarily sought the services provided and consent to the treatment.

Even though the risk of complication is extremely low, the following can occur: Potential risk include

swelling, bruising, scabbing, itching, milia, hyper/hypo-pigmentation, a very small risk of scarring and failure to achieve the desired results. -
Allergic or delayed inflammatory reactions can develop. Prior to initiation of treatment, any suspicious pigmented lesions should be correctly identified by a physician to be benign. A medical certificate to this effect is required.
I consent to photographs taken to evaluate effectiveness. Photographs revealing my identity will not be used without consent.
I understand the sensation of needling treatment is sometimes uncomfortable and feels like a prickly and a mild sun burn sensation after treatment.

Signature *

By signing and ticking this, I have read and agree to the clinic procedures of the treatment(s) that I have availed and abide from the instructions.