L Aesthetics
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Skin Needling Consent Form
Patient Info
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
D.O.B
(Required)
DD slash MM slash YYYY
Questions
Do you have any allergies?
(Required)
eg latex, Peanuts, Shelfish
Are you currently on or have taken the following medications or have taken the following in the last 6 months?
(Required)
Antibiotics
Roaccutane/Accutane
Prescription vitamin A
Skin bleaching agents
Blood thinning medications
Are currently experiencing?
(Required)
Diabetes
Pregnancy Keloid Scarring
HIV Herpes Simplex (cold sores)
Rosacea Acne
Sunburn Haemophilia
Have you had any of the following in the last 6 months?
(Required)
IPL Laser
LED therapy Microdermabrasion
Chemical peel Anti-wrinkle/dermal fillers
Cosmetic tattooing Facial/cosmetic surgery
Do you use any topical cosmeceutical ingredients?
E.g. Glycolic/lactic acid, vit A/C, Benzoyl peroxide.
Patient Consent
Consent
(Required)
I understand I am to use SPF sunscreen every day during the recovery period and beyond, commencing the day after treatment. I also understand I must not expose my skin directly to the sun on the day of the treatment prior to and post treatment.
I understand I must not apply makeup until the day after treatment and then it should be mineral based and only used if necessary.
I understand that numerous treatments may be required to reach final results.
I understand I’m required to refrain from the following activities immediately before and whilst recovering from the skin needling treatment:
• excessive exercise
• spa or sauna
• swimming in a chlorinated pool
• chemical peel / microdermabrasion / dermabrasion
• IPL / laser
• infrared light exposure
• anti-wrinkle and dermal filler injections
• spray or self-tanning
• cosmetic tattooing
• use of active ingredients
• shaving or waxing
• direct sun exposure
I have answered all the questions and provided the correct answers to the best of my knowledge and am ready to undergo skin needling clinical treatment.
Name
(Required)
First
Last
Date
DD slash MM slash YYYY
Signature
(Required)
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