Microneedling Intake and Consent Form

Please arrive at the appointment with clean skin, without makeup, sunscreen, or skincare products!

Acknowledgment of Risks

By checking and initialing below, I acknowledge and accept the following

1. Potential Risks

Microneedling treatment is safe for most clients, but there is always a possibility of:

✦ Redness, dryness, itching, allergic reactions, infection, hyperpigmentation, bruising, bleeding, scarring, breakouts, irritation, swelling. and/or peeling.

✦ These reactions are not indicative of improper application or malpractice but are dependent on the clients unique skin and health conditions.

I confirm that I have read, understood, and accept the potential risks

2. Before Treatment

Please be advised of the following instructions before your treatment.

✦ Avoid recent exfoliation, scrubs, waxing, retinoid acids, and other active ingredients such as but not limited to AHAs, BHAs, and Vitamin C, bleaching agents, and acne products at least three days prior to treatment

✦ No recent sun exposure or laser hair removal for at least 2 weeks before treatment.

✦ Avoid blood thinners, aspirin, ibuprofen, or alcohol 24-48 hours before treatment.

✦ No active infections, open wounds, or cold sores.

I confirm that I have read, understood, and agree to the pre-treatment care instructions

Initials

Please read each statement, initial in each box and sign this document to accept your acknowledgement and agreement of the following:

I affirm that I am 18 years of age or older, and competent to sign this release on my own behalf. I have read and fully understand and accept this agreement and all information detailed throughout this consent and intake form. I understand the service and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the technician and or Kate Aglaia Aesthetics owner responsible for any of my conditions that weren’t disclosed at the time of the skin care service, which may be affected by the treatment performed. I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my technician. Although it is impossible to list every potential risk and complication, I have been informed of possible risks and complications. I have also, to the best of my knowledge, given an accurate account of my medical history, including known allergies or prescription drugs or products I am currently ingesting or using topically. I understand and accept the nature and purpose of the products to be used in this service has been explained to me, along with the risks and hazards involved.

Signature

To be signed by parent/guardian if the participant is under 18

Today's Date

First and Last Name

Date of Birth

Month

Day

Year

Phone

Address

Have you taken any medications, including Accutane, isotretinoin, anticoagulants, etc., in the last 12 months?

Have you previously had a microneedling treatment?

If yes, please explain

Are there any other conditions or situations about you that may affect the outcome of the treatment, which haven’t been covered in the previous questions, that you need to inform your technician at Kate Aglaia Aesthetics about?

How did you hear about us?

I hereby give my consent and authorize Kate Aglaia Aesthetics to perform a microneedling treatment, fully acknowledging the potential risks and complications involved.

I understand that microneedling treatment has not been evaluated for the following patient populations. As such, precautions should be taken when determining whether to treat individuals with: scars or stretch marks less than one year old; women who are pregnant or nursing; keloid scars; a history of eczema, psoriasis, or other chronic conditions; a history of actinic (solar) keratosis; a history of herpes simplex infections; diabetes or wound-healing deficiencies; patients on immunosuppressive therapy; or skin with raised moles or warts in the targeted area.

If I have one of the conditions stated above, I must provide a doctor's note stating that it is safe for me to proceed with the treatment.

After Care

Please be advised of the following instructions after your treatment:

✦ Do not wash, touch, or apply any products to your face during the first 24 hours. Be sure to keep the area clean and free from any irritants.

✦ After 24 hours, you can wash the treated area with a gentle cleanser.

✦ Apply sunscreen with a minimum SPF of 30 at least 2 to 3 times a day and keep the area moisturized and hydrated with a gentle.

✦ Avoid actives, exfoliants, or harsh products (such as AHAS, BHAs, retinoids, Vitamin C, etc.) for 7 days or until the treated area is completely healed.

✦ No sun exposure for 2 weeks.

✦ Avoid makeup, sweat, heat, sauna, swimming pools, and intense workouts for 48 hours.

I confirm that I have read, understood, and agree to the after care treatment instructions

I understand and accept that there are risks associated with getting a microneedling treatment. I understand that no warranty, guarantee, or assurance has been made to me as a result of the microneedling technique and that the final result cannot be guaranteed as each skin type is unique. I further acknowledge that, as part of the procedure other potential risks can occur. I agree that if I experience any conditions during or after the procedure, I will notify Kate Aglaia Aesthetics and consult a physician at my own expense.

I fully release my technician & Kate Aglaia Aesthetics from any liability related to this procedure, during & after its completion. The procedure will be performed with utmost safety & proper technique, using tools & products the technician is trained in.

Signature

Today's Date

I understand payment is due in full at the time of service. Cancellations or rescheduling must be made 48 hours in advance, or a 50% charge applies. No-shows are charged 75%. Late arrivals (10+ mins) incur a no-show fee and must reschedule.

Microneedling Intake and Consent Form

**Please arrive at the appointment with clean skin, without makeup, sunscreen, or skincare products!**

Please arrive at the appointment with clean skin, without makeup, sunscreen, or skincare products!