Microchanneling Consent Form

Please Fill Consent Form For Microchanneling

PATIENT INFORMATION

Name

Date

Phone

How did you hear about us?

Microchanneling is an elective procedure for cosmetic purposes only. I have had the opportunity to ask questions and understand the nature, goals, limitations, and possible complications of this treatment. I have had the opportunity to discuss alternative forms of treatment and understand that results may vary.

CONTRAINDICATIONS

While Microchanneling treatments are safe and effective for most women and men, there are some people who will not be good candidates for treatments. Here is a general contraindication:

Pregnancy - if you are pregnant or nursing you are advised to not receive any Microchanneling treatments. To date there have been no studies conducted to see what effects these treatments may have on the unborn child, but as a general rule, pregnant women should stay away from any type of cosmetic/elective procedures.
Diabetes - unstable diabetes patients should not be treated due to healing problems.
Active Herpes Simplex in the treatment area - treatment is possible once the outbreak is healed, however it may be advisable to take prescription strength antiviral medication to keep this condition in remission during the treatment series.
Dry skin - if your skin is overly dry, you will need to start moisturizing and ensure the condition is under control prior to undergoing any treatment.
Any active inflammatory skin condition - e.g. eczema, psoriasis, infection, rash or any type of dermatitis at the treatment site (because it may aggravate the condition).

I have no allergies to anything that I am aware of, including aloe vera or benzoyl alcohol

I understand that I must verbally inform my technician of any concerns, use of medication (including pain medications) or medical conditions I have before receiving MicroChanneling.

I am not under the influence of alcohol, drugs or any other substances.

I release ProCell Therapies, and its subsidiaries and representatives, of all claims for injury seen or unseen that may occur as a result of this procedure.

I understand that no promise has been made to me as to the final result of the procedure.

I have been given the opportunity to address all of my questions and concerns about the risks, hazards, and aftercare for the procedure(s) that will be performed with my consent.

Are you over 18 years of age?

Yes No

(initial) I understand that if I have a history of cold sores, herpes or fever blisters I must take my medication prescribed by my physician in advance or tell the technician to skip treatment around my lips.

Signature：

Please check if yes

Are you sensitive to Latex?

Have you had a chemical or LASER peel? If so, when?

Do you have trouble healing?

Have you had any botox or fillers? If so, when?

Are you currently undergoing radiation or chemotherapy?

Are you currently using Accutane, Retin-A, AHA, or other exfoliating skin care

Are you allergic to any metals? If so, what?

Are you currently taking anti-inflammatory medications or steroids?

Are you allergic to any anesthetics, (any of the “caines”)? If so, which?

Do you have a history of skin disease?

Do you have a history of skin sensitivity?

Are you currently taking vitamin A or E in any form?

Are you pregnant or nursing?

Are you currently being treated by a dermatologist? If yes, what for?

Derm name

Please check any that apply to you

Heart Condition

Hepatitis

HIV

Cold Sores

Hyper Pigment

Smoker

Keloid Above Neck

Allergic to Steel

Accutane in last 2 yrs

Diabetes (uncontrolled)

Chronic Skin Disease

Hemophilia

Initial

Date

Patient name

Date

I authorize

to perform Microchanneling on my skin,

and to apply topical preparations as determined necessary. I understand that Microchanneling 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, peeling, 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 understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s).

Initial

I consent and authorize the use of any photographs of me for the purposes of marketing and education：

Yes No

I consent and authorize the use of any photographs of me for the purposes of marketing and education：

Yes No

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.

Patient Signature

Step 1 of 3

33%

Patient information

Name(Required)

First Last

Date(Required)

Month

Day

Year

Phone(Required)

Email(Required)

How did you hear about us?

Contraindications

While Microchanneling treatments are safe and effective for most women and men, there are some people who will not be good candidates for treatments. Here is a general contraindication:

Pregnancy - if you are pregnant or nursing you are advised to not receive any Microchanneling treatments. To date there have been no studies conducted to see what effects these treatments may have on the unborn child, but as a general rule, pregnant women should stay away from any type of cosmetic/elective procedures.
Diabetes - unstable diabetes patients should not be treated due to healing problems.
Active Herpes Simplex in the treatment area - treatment is possible once the outbreak is healed, however it may be advisable to take prescription strength antiviral medication to keep this condition in remission during the treatment series.
Dry skin - if your skin is overly dry, you will need to start moisturizing and ensure the condition is under control prior to undergoing any treatment.
Any active inflammatory skin condition - e.g. eczema, psoriasis, infection, rash or any type of dermatitis at the treatment site (because it may aggravate the condition).

Consent(Required)

I have no allergies to anything that I am aware of, including aloe vera or benzoyl alcohol(Required)

Consent(Required)

I understand that I must verbally inform my technician of any concerns, use of medication (including pain medications) or medical conditions I have before receiving MicroChanneling.(Required)

Consent(Required)

I am not under the influence of alcohol, drugs or any other substances.(Required)

Consent(Required)

I release ProCell Therapies, and its subsidiaries and representatives, of all claims for injury seen or unseen that may occur as a result of this procedure.(Required)

Consent(Required)

I understand that no promise has been made to me as to the final result of the procedure.(Required)

Consent(Required)

I have been given the opportunity to address all of my questions and concerns about the risks, hazards, and aftercare for the procedure(s) that will be performed with my consent.(Required)

Are you over 18 years of age?(Required)

Yes

I understand that if I have a history of cold sores, herpes or fever blisters I must take my medication prescribed by my physician in advance or tell the technician to skip treatment around my lips.(Required)

Signature(Required)

Are you sensitive to Latex?(Required)

Yes

Have you had a chemical or LASER peel?(Required)

Yes

When did you have a chemical or LASER peel?(Required)

Do you have trouble healing?(Required)

Yes

Have you had any botox or fillers?(Required)

Yes

When did you have botox or fillers?(Required)

Are you currently undergoing radiation or chemotherapy?(Required)

Yes

Are you currently using Accutane, Retin-A, AHA, or other exfoliating skin care?(Required)

Yes

Are you allergic to any metals?(Required)

Yes

What metals are you allergic to?(Required)

Are you currently taking anti-inflammatory medications or steroids?(Required)

Yes

Are you allergic to any anesthetics, (any of the “caines”)?(Required)

Yes

What anesthetics are you allergic to?(Required)

Do you have a history of skin disease?(Required)

Yes

Do you have a history of skin sensitivity?(Required)

Yes

Are you currently taking vitamin A or E in any form?(Required)

Yes

Are you pregnant or nursing?(Required)

Yes

Are you currently being treated by a dermatologist?(Required)

Yes

What are you being treated for?(Required)

Dermatologist name(Required)

Please check any that apply to you

Heart Condition

Cold Sores

Keloid Above Neck

Diabetes (uncontrolled)

Hepatitis

Hyper Pigment

Allergic to Steel

Chronic Skin Disease

HIV

Smoker

Accutane in last 2 yrs

Hemophilia

Initial(Required)

Date(Required)

Month

Day

Year

Patient name(Required)

First Last

Date(Required)

Month

Day

Year

I authorize

Provider name(Required)

to perform Microchanneling on my skin, and to apply topical preparations as determined necessary. I understand that Microchanneling 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, peeling, 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 taking of before and after photographs of the said procedure(s) are a condition of such procedure(s).

Initial(Required)

Consent(Required)

I consent and authorize the use of any photographs of me for the purposes of marketing and education.(Required)

Consent(Required)

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.(Required)

Signature(Required)

Date(Required)

Month

Day

Year

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Microchanneling Consent Form

Please Fill Consent Form For Microchanneling

Patient information

Contraindications

Treat yourself

I'm looking forward to working with you!