The Skin Edit · Abbotsford, BC

Nano Needling
Consent Form

Please read each section carefully and discuss any questions with your practitioner before signing.

Client Information

First Name

Last Name

Date of Birth

Phone

Consultation and photographs

I have received a consultation with an Esthetician/Skin Care Specialist and I consent to the treatment of Nano Skin Needling to be carried out upon myself. I understand that I am required to have photographs taken before and after treatment for my medical records.

I consent to the consultation, treatment, and before/after photographs as described above.

Client acknowledgements

I acknowledge that I have not used Accutane or any medication for the same purpose during the last 6 months.I acknowledge that if I have ever had a cold sore or fever blister, I have informed the practitioner and should consider taking an anti-viral medication to help avoid a possible breakout. The medication should be used two days before, and two days after any aggressive facial exfoliation treatment.I acknowledge that there is no guarantee that dark discoloration of skin will be reduced or fade. Pigmentation may improve or darken with successive treatments. I acknowledge the need for proper skin care home regimen.I acknowledge that my skin may experience temporary irritation, tightness and redness.I acknowledge that if I fail to use minimal sunscreen (SPF 30), I am more susceptible to sunburn, skin damage and hyperpigmentation.I acknowledge that this treatment is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied. 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.

Consent and agreement

I understand my obligation to follow the instructions closely and visit the office as directed. I certify that I have read the above consent and fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. I also agree to hold harmless and release from any liability The Skin Edit or any of its officers, directors, or employees for any condition or result, known or unknown that may arise as a result of any treatment that I receive.

Client signature

Signature (type your full name)

Date