Microneedling Safety Questionnaire and Consent Renewal


The following questions are required to ensure the safety and efficacy of the laser treatment. All questions pertain solely to the area being treated. For example: if you recently had a chemical peel on your face and are having laser hair removal on the underarms today you would check ‘no’ as the chemical peel was not performed on the area being treated.

 
In the last 72 hours, have you had any clinical peeling procedure done?    

 
In the last 72 hours, have you used any acid based products (salicylic, glycolic, etc.)? 

 
In the last 72 hours, have you used any retinol based products?* 
 

 
In the last 4 weeks, have you had any waxing, tweezing or threading?

 
In the last 4 weeks, have you experienced prolonged unprotected sun exposure?

 
In the last 2 weeks, have you applied any self-tanner or bronzing products?

 
In the last 2 weeks, have you taken any medications that make you sensitive to the sun?  Common examples: Antibiotics, diuretics, antifungals, acne medications and St. John’s Wart.   

 
Are you currently pregnant or nursing?

 
Pacemaker or Defibrillator?

I acknowledge that all information contributed by me is true and accurate to the best of my knowledge.  I will inform my skin care professional if there are any changes to my medications, recent prolonged sun exposure or topical bronzing usage, or any new contraindications for the treatments outlined in my treatment plan.  I will immediately contact the facility if any adverse reactions appear following the procedure. I have been advised of the contraindications for laser hair reduction and understand that with any laser treatment there are associated risks such as burns and blisters that may result in scarring of the skin. I consent to the treatment described above with its associated risks. I hereby release the medical director, esthetician, and the facility from liability associated with this procedure.

     Date:  

Cancellation Policy:

Your allocated appointment times are reserved especially for you and are very important to us. We have implemented this cancellation policy because we value the business of our clients and the time of our staff. All of our policies are designed to benefit our current clients and our future clientele. Therefore, we respectfully request at least 24 hours’ notice for adjustments to your appointments and for cancellations.  Please understand that when you forget or cancel your appointment without giving enough notice, we miss the opportunity to fill that appointment time and clients on our waiting list miss the opportunity to receive services they need.

I understand that as a new or current client of Skinlogic Med Spa that I supply a credit card to have on our files. All cards on file are added to the system via a secure electronic process that ensures the information is encrypted and remains secure. In the event that we do not receive the required 24 hour notice for adjustments and cancellations a $50 fee will be applied to your card.

I have read the above Cancellation Policy and agree to its terms and conditions.  I hereby give my consent for  Skinlogic Med Spa to securely store my credit card on file and authorize Skinlogic Med Spa to charge my card if I cancel less than 24 hours before any future scheduled appointments.

 

Issues in signing document?  Scroll up to see required areas marked in red that you need to fill out then re-sign.

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Microneedling Safety Questionnaire and Consent Renewal
lock iconUnique Document ID: ace016d0007cae14ec93a2d49383c9003a315ca4
Timestamp Audit
May 20, 2020 8:54 pm PSTMicroneedling Safety Questionnaire and Consent Renewal Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 154.9.128.131