The Skin Edit by Melissa Jordan

    The Skin Edit · Abbotsford, BC

    Clinical & RF Microneedling
    Intake & Consent Form

    First-time client intake and informed consent. Please complete all sections accurately before your appointment.

    1. Client Information

    2. Medical & Skin Health Screening

    Please answer all questions accurately. A Yes response does not automatically prevent treatment, but may require further assessment, treatment modification, postponement, or medical clearance.

    Do you have any current or chronic medical illness, including diabetes, autoimmune disease, immune suppression, blood disorders, cancer, or a condition that may impair healing?

    Do you have any current or chronic skin condition in the treatment area, including eczema, psoriasis, rosacea, vitiligo, melasma, dermatitis, scleroderma, collagen vascular disease, or skin cancer?

    Are you currently under a physician's care for any medical condition?

    Are you pregnant, could you be pregnant, or are you currently nursing?

    Do you have a history of cold sores/herpes simplex in or near the treatment area?

    Do you have a history of keloid or hypertrophic (raised) scarring?

    Do you currently have open sores, cuts, wounds, active acne lesions, bacterial/fungal/viral infection, or irritated skin in the treatment area?

    Have you had radiation therapy in the treatment area?

    Do you have allergies to medications, latex, topical products, gold, or other substances relevant to treatment?

    3. Medications, Products & Recent Treatments

    Do you take any prescription/non-prescription medications, aspirin, vitamins, herbal products, natural supplements, steroids, anticoagulants, antiplatelets, thrombolytics, anti-inflammatory drugs, or other blood-thinning products?

    Have you used isotretinoin (Accutane or similar medication) within the last 6-12 months?

    Have you used tretinoin/Retin-A/Renova or another prescription retinoid within the last 14 days?

    Within the last 3 months, have you used glycolic/AHA/BHA products or had chemical peels, exfoliating, resurfacing, or other aggressive facial treatments?

    Have you had Botox, Dysport or other neuromodulator treatment within the last 2-4 weeks in or near the planned treatment area?

    Have you had dermal filler or another injectable treatment in or near the planned treatment area recently?

    Do you have permanent makeup, tattoos, implants, or fillers in or near the treatment area?

    Have you had recent unprotected sun exposure, tanning bed/lamp exposure, or used tanning/sunless-tanning products?

    4. RF Microneedling — Additional Safety Screening

    Complete this section if RF Microneedling (Potenza) is being considered.

    Do you have a pacemaker, implantable cardiac defibrillator (ICD), cardiac resynchronization device, or another implanted electronic device?

    Do you have any metal implants in or near the treatment area?

    Do you have reduced or absent nerve sensation, including insensitivity to heat, in the treatment area?

    Do you have a history of heat urticaria or unusual sensitivity to heat?

    5. Treatment Information, Expected Reactions & Risks

    Clinical Microneedling: Clinical microneedling creates controlled micro-injuries in the skin using a sterile needle cartridge. The treatment is intended to stimulate the skin's repair response and collagen production. More than one treatment may be recommended.

    RF Microneedling (Potenza): RF microneedling combines microneedling with radiofrequency energy that delivers controlled heat into tissue. Client feedback during treatment is important. Treatment should not be performed over cut, wounded, infected skin or where heat sensation is impaired.

    Expected reactions and possible risks: Temporary redness, warmth, tightness, tenderness, itching, dryness/flaking, swelling, bruising, pinpoint bleeding or crusting may occur. Other possible risks include cold-sore reactivation, infection, burns (particularly with RF treatment), temporary or persistent pigment changes, delayed healing, and scarring. Individual responses vary and unforeseen complications are possible.

    Results: Results vary between individuals. No specific result, degree of improvement, or duration of result can be predicted or guaranteed. A series of treatments and appropriate home care may be recommended.

    6. Client Acknowledgement & Consent

    7. Before & After Photography Consent

    Clinical record photography: Before-and-after photographs may be useful for documenting baseline condition, treatment planning and monitoring progress. These images form part of the client's confidential treatment record.

    Optional marketing / educational use: This permission is separate from treatment consent. Declining marketing use will not affect my ability to receive treatment.

    8. Signatures

    By typing my name in the client signature field, I acknowledge that it represents my electronic signature and confirms my consent to the treatment selected above.

    Please complete all required fields, screening questions, acknowledgements, and signature before submitting.

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