INTAKE FORM | SIGNATURE FACIALS

ALL INFORMATION IS CONFIDENTIAL.

Name (required)

Date (required)

Address (required)

Email (required)

Cell Phone (required)

Whom may we thank for your referral?

Which concerns apply to your skin? (required)

Other concerns:

What skincare products do you use?

List the name brands of your skincare products:

Please check the prescription medications you are currently using:

Other:

Are you allergic to any cosmetic ingredient, medication or food? Please list:

In the past 30 days, please list all professional facial or dermatology services you have received (i.e. Chemical Peel, Microdermabrasion, Laser, Botox, etc. (required)

Please take a moment to carefully read the following list of conditions and check any that have affected your health either recently or in the past: (required)

If yes, please include additional information:

I confirm that all information provided is true and accurate to the best of my knowledge. I accept full responsibility for informing my esthetician of any physical or mental condition that may affect my treatment or results. I understand that my service is therapeutic in nature and agree to notify my esthetician immediately of any discomfort during my treatment. (required)

The MDPen™ skin needling system allows for controlled induction of the skin’s self-repair mechanism by creating micro injuries in the skin to trigger new collagen synthesis, while not posing the risk of permanent scarring. The result is smoother, firmer, and younger-looking skin. Skin needling treatments are performed in a safe and precise manner with the sterile MDPen™ needlehead and are normally completed within 30-60 minutes, depending on the selected area.

Side Effects

After the procedure, the skin may be red and flushed in appearance, similar to moderate sunburn. In the treatment area, skin tightness and mild sensitivity may also be experienced. These side effects will diminish within a few hours following treatment and over the next 24 hours. After 3 days, there will be little evidence that the procedure has taken place.

Contraindications

Contraindications and precautions include: keloid or raised scarring; history of eczema, psoriasis, actinic (solar) keratosis, herpes simplex infections, diabetes, and other chronic conditions; presence of raised moles, warts, or any raised lesions in the target area. Absolute contraindications include: scleroderma, collagen vascular diseases, or cardiac abnormalities; rosacea or blood clotting problems; active bacterial or fungal infections; immuno-suppression; scars less than 6 months old; and facial rollers used in the past 2 - 4 weeks. Treatment is not recommended for patients who are pregnant or nursing.

Patient Consent

I understand that results will vary among individuals. I understand that although I may see a change after my first treatment, I may require a series of sessions to obtain my desired outcome.The procedure and side effects have been explained to me, including alternative methods. I understand the advantages and disadvantages of this procedure.I am aware that although good results are expected, the possibility and nature of complications cannot be accurately advised; therefore, there can be no guarantee, expressed or implied, either to the success or other result of the treatment. I am aware that the MDPen™ treatment is not permanent and natural degradation will occur over time.I agree that I have read (or that it has been read to me) and understand this consent form, and that I understand the information contained in it.I have had the opportunity to ask any questions about the treatment, including risks and alternatives, and I acknowledge that all my questions about the procedure have been answered to my satisfaction. (required)