Patient Consent Form For Micro Needling Treatment

Micro-needling is based on the skin’s natural ability to repair itself. Micro-needling treatments create superficial “micro-channels” to the outermost layer of the skin, inducing the healing process including new collagen production.  Micro-needling has been shown to reduce the visibility of acne scars, fine lines, and wrinkles, diminish hyperpigmentation, and improve skin tone and texture.

I understand possible side effects include and are not limited to: slight or extreme redness, histamine reaction, swelling, stinging, itchy, tender, dry or flaking skin. In rare instances, hyperpigmentation/hypopigmentation, scarring, or infection can occur. I UNDERSTAND THAT I SHOULD ONLY APPLY PRODUCTS RECOMMEDED BY MY CLINICIAN POST TREATMENT.

Most side effects will gradually diminish over time as healing may take several days. Notify your clinician if any side effects cause extreme discomfort or any unexpected problems occur immediately.

I have avoided the following products/procedures THREE DAYS prior to treatment:

• Topical prescriptions including but not limited to Retin-A, Tretinoin, Differin, Tazorac
• Abrasive scrubs or other exfoliating products

I have not had any cosmetic injections within the last TWO WEEKS

(Print Name) hereby authorize Salon Identity to perform my Micro-needling treatments.

Please call 03 9863 6966 with any questions or concerns.

I am undergoing treatment of my own free will.  I agree that this procedure is being performed for cosmetic reasons and that no guarantee can be made as to the exact results of this procedure.  I understand that every precaution will be taken to prevent complications and that complications from this procedure are rare, they can and

Although the results are usually dramatic I have been informed that the practice of medicine is not an exact science and that no guarantees can be or have been made concerning the expected results in my case. Multiple treatments may be necessary to achieve optimal results.