Please read and initial where indicated.
Micro-needling devices intentionally create very superficial “micro-injuries” 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, resulting in smoother, firmer, younger-looking skin. Skin needling treatments are
performed in a safe and precise manner with the sterile devices and are normally completed within 30-60
minutes, depending on the selected area.
___ Although, the majority of patients do not experience any complications with micro-needling, it is
important you understand that risks do exist. The micro-needling procedure is minimally invasive,
utilizing a set of micro-needles to inflict multiple, tiny, puncture/lacerations to the outermost layer of the
skin. Because micro-needling penetrates the skin, it inherently carries health risks, including but not
limited to those listed below. You should discuss any and all health concerns with your esthetician or
attending healthcare provider PRIOR to signing this consent form.
___ I understand that micro-needling may cause infection, pigment/color change, scarring, pain, persistent
redness, itching, and/or swelling, and/or an allergic reaction.
___ I understand that after the procedure, the skin will be red, with mild swelling and/or bruising, and
might feel tight and sensitive to the touch. Although these symptoms may take 2-3 days to resolve
completely, they will diminish significantly within a few hours after treatment.
___ I understand there are certain contraindications that would preclude me from receiving micro-needling
treatments including active acne, active infection of any type (bacterial, viral, or fungal), cardiac
disease/abnormalities, collagen vascular disease, eczema, psoriasis, or dermatitis, hemophilia/
bleeding disorders, keloid/hypertrophic scaring, pregnancy/lactation, raised lesions (moles, warts,
etc.), skin cancer, sunburn, tattoos, telangiectasia/erythema, uncontrolled diabetes, vascular lesions
(hemangiomas), rosacea, and scleroderma.
___ I understand that the use of Botox®, Juvederm®, Restylane®, and any other injectable must be
disclosed prior to treatment.
___ I understand that there are some contraindicated medications: blood thinner medications,
chemotherapy or radiation, hormone replacement therapy, recent use of some topical medication.
___ I understand that micro-needling is contraindicated within 72 hours of waxing, and within 1-3 weeks of
a chemical peel.
___ I understand that while the goal of this treatment is to improve the vitality of the skin, no specific
guarantees of the result can or have been made.
___ I understand that it is imperative to my health that I disclose all of the information requested in the
Client Profile/Health History.
___ I have cited all conditions and circumstances regarding my health history, medications being taken, and
any past reactions to products or medications.
Informed Consent: Micro-needling
Associated Skin Care Professionals
member
Continued a
