MICRONEEDLING NEDERLAND TX · CONSENT FORM

Micro-Needling Consent Form

Welcome to our microneedling Nederland TX consent form. Please read it and fill it out before your treatment.

How Microneedling Works

Your skin can repair itself. This treatment uses that natural ability. Tiny micro-channels form in the top layer of skin. In response, your skin starts to heal and build new collagen. Over time, many clients see softer acne scars, fine lines and wrinkles. In addition, dark spots can fade, and skin tone and texture often look smoother.

Book Microneedling in Nederland or Lumberton

First, choose your studio. You can visit us at 3205 Nederland Ave (Google Maps). Alternatively, stop by 211 S Main St in Lumberton. Then book in Nederland or book micro-needling in Lumberton, TX. Also, see prices on our services page, or read about our head spa and facials.

Consent Form

Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ

Micro-Needling Consent Form

Name *

Phone *

Birthday *

Email *

I Hereby authorize and direct the Fairys Lashes and Brows to perform my Micro-needling treatments.

Tick the box to confirm you agree *

I understand possible side effects include and are not limited to: slight or extreme redness, histamine reaction, swelling, stinging, itchy, tender, dry or flaking skin. In rare instances, hyperpigmentation/hypopigmentation, scarring, or infection can occur. I UNDERSTAND THAT I SHOULD ONLY APPLY PRODUCTS RECOMMEDED BY MY CLINICIAN POST TREATMENT. Improvement of the skin may also be accomplished by other treatments. Options include laser skin surface treatments, chemical peels, microdermabrasion, and facials. Other options not mentioned here may exist. Risk and potential complications are associated with alternative treatments. Most side effects will gradually diminish over time as healing may take several days. Notify your clinician if any side effects cause extreme discomfort or any unexpected problems occur immediately.

I have avoided the following products/procedures THREE DAYS prior to treatment: *

- Topical prescriptions including but not limited to Retin-A, Tretinoin, Differin, Tazorac, Abrasive scrubs or other exfoliating products I have not had any cosmetic injections within the last TWO WEEKS

TREATMENT CONSENT

Notify your technician PRIOR TO SIGNING THIS CONSENT if any of the following apply to you:

Cold sores(or history), warts, open skin lesions, sunburn, extreme sensitivity, dermatitis, rosacea
Blood thinning medications
Accutane or generic within the past year
Pregnant or breastfeeding
Received chemotherapy or radiation therapy
Collagen Vascular Disease
Eczema, Psoriasis, or Dermatitis
Hemophilia / bleeding disorders
Keloid/hypertrophic scaring
History of autoimmune disease or any condition that may weaken you immune system

Client Consent & Acknowledgment *

I am undergoing treatment of my own free will. I agree that this procedure is being performed for cosmetic reasons and that no guarantee can be made as to the exact results of this procedure. I understand that every precaution will be taken to prevent complications and that complications from this procedure are rare, they can and sometimes do occur. Although the results are usually dramatic I have been informed that the practice of medicine is not an exact science and that no guarantees can be or have been made concerning the expected results in my case. Multiple treatments may be necessary to achieve optimal results.

ACKNOWLEDGMENT:
BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS MICRONEEDLING CONSENT FORM AND THAT THE DISCLOSURES REFERRED TO HEREIN WERE MADE TO ME.

Printed Name *

Date *

Technician’s Name *

Date *

Technician’s Signature *

Fairy - Nederland Tx

Fairy - Lumberton Tx

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Micro-Needling Consent Form

How Microneedling Works

Book Microneedling in Nederland or Lumberton

Consent Form

Micro-Needling Consent Form

TREATMENT CONSENT

Contact us

Business hours

Fairy - Nederland Tx

Fairy - Lumberton Tx

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