Skin Needling "*" indicates required fields CLIENT DETAILSFull Name Email* Date MM slash DD slash YYYY Address Mobile* Suburb Postcode Treatment Area Face Neck Décolletage Hands Scarring Stretch Marks Desired Outcome LIFESTYLEOccupation Exercise 0 times a week 1 - 3 times a week 4 - 7 times a week Water Intake 0 - 3 glasses a day 1 - 2 litres a day 2 - 3 litres a day Stress Levels Low Moderate High Sleep 0 - 5 hours a night 6 - 7 hours a night 8+ hours a night Diet Poor Moderate Balanced Digestion Sluggish Regular Imbalanced Smoking Yes No SKINCARE PRODUCTS Please tick if you have used products containing any of the following ingredients on the area to be treated:Skincare Products Benzoyl Peroxide Or Adapalene (Differin) Alpha Beta Hydroxy Acids (Glycolic Acid, Salicylic Acid) Hydroquinone, Azelaic Acid, Kojic Acid Retinoids (Vitamin A) Do You Wear SPF Daily? Yes No Current Skincare Routine/Brands?Previous Procedures Hair Removal (Wax, Threading Etc) Injectables/Botox Microdermabrasion Cosmetic Tattoo, Tattoos Skin Needling Plastic Surgery Radio Frequency (RF) Laser or IPL Other Please tick if you have had any of the following procedures:Other Skin Care Sun Exposure Yes No Medical History Pregnant Breastfeeding Psoriasis Roaccutane Herpes Seizures Cancer Warts Or Skin Tags Glaucoma Cold Sores Diabetes Scleroderma Eczema Shingles Rosacea Thyroid Imbalance Congenital / Idiopathic Methemoglobinemia Liver Disease (Ie Hepatitis) Asthma / Respiratory Disease Skin Cancer / Unusual Moles Moles That Have Changed, Itched Or Bled Reaction To Topical Anaesthetics (Ie. Emla, Xylocane) Life Threatening Allergies Anticoagulant Medication Antibiotics In The Last Two Months HIV (Human Immunodeficiency Virus) Actinic Keratosis (Solar) Atypical Pseudocholinesterase Disease Of Nerves / Muscle Haemophilia (Bruise or Bleed Easily) Easy Bruising / Bleeding Cardiac Conditions / Arrhythmia (Blood Pressure) Photosensitive Disorder (i.e. Lupus) Vaccine in the Last Two Months (Ie. Flu Shot, Covid) Low Immune System (Current or in the Last Month) Other Please tick if you have had any of the following procedures:Other Medical History Does Your Skin Form Thick Or Raised Scars From Cuts Or Bruises? (Ie. Keloid Scarring) Yes No After Injury Does Your Skin Darken (Hyperpigmentation) Lighten (Hypopigmentation) Unsure MedicationSKIN NEEDLING CONSENT FORM Microneedling (collagen induction therapy) is a pen containing very fine sterile needles that create microchannels within the skin’s surface by a controlled vibrating action. This stimulates our natural healing process, promoting regeneration of skin cells and new collagen production. Collagen production continues to enhance skin appearance and refine the contour for up to 18 months following treatment. Results are noticeable after one treatment, however to achieve the best results we recommend a series of at least four treatments. Keeping in mind individual results depend on many factors; thus it is extremely difficult to advise on the exact number of treatments required. What to Expect Treatment is uncomfortable momentarily but well tolerated, more often virtually painless with a mild prickling sensation. Minor redness, swelling and bleeding is possible due to the adjustable depth and number of times we treat target areas. Your skin must be prepped a minimum 2 weeks prior to each treatment with a 7 day aftercare plan post treatment, or as directed by your therapist. (Please see attached pre and post care information sheet). Skin may feel sunburnt following treatment and should subside in the following 12-48 hours, very rarely the skin may stay red for up to 72 hours. We advise having your needling session late afternoon/night and plan to be indoors with no makeup for at least 48hrs post your first treatment. From there may be less downtime in your following sessions, once we see how quickly the skin heals, as for most redness will only last a few hours and light mineral makeup can be applied after 24hrs. Skin may feel rough, tight, dry or flaky for 2-7 days following treatment as the skin rejuvenates - you may then gently exfoliate after 7 days. Topical Anaesthetic Topical anaesthetic can be applied to reduce discomfort but for most clients is not needed. This would be at an extra cost and applied by yourself 30 minutes prior to your treatment or as advised by Pharmacist. However, you do achieve better results without and your therapist will only work within your comfort level. If your therapist decides you need a stronger/deeper treatment later on in your microneedling series to treat stubborn skin concerns, we can then implement the use of topical anesthetic. Possible side effects can include: Temporary discomfort, flushing, histamine reaction, bruising, swelling, stinging, itching, tender, rough, dry or flaking skin. The sensation of feeling sunburnt may persist for up to 4 days. In very rare instances risks associated may include: crusting, scarring, freckles may temporarily lighten or disappear, hyperpigmentation/hypopigmentation and/or infection can occur. A history of cold sores may result in an outbreak therefore prophylactic treatment is strongly recommended prior to and following treatment. Other potential risks include allergic reaction to topical anaesthetic and/or failure to achieve desired result. General caution • If you have a medical condition, please seek independent advice and obtain written consent from your treating Doctor. Risk of developing an unknown allergic reaction to allergen. • In the event of rash or anaphylaxis the treatment will cease and immediate medical attention will be sought. • Risk of infection due to intentional micro injury to the skin surface. Maintaining meticulous hygiene practices pre and post treatment is advised. • Risk of developing Delayed Hypersensitivity Allergic Reaction. Presenting as onset of chronic erythema days to weeks following treatment progressing to systemic infection. Signs and symptoms include: joint pain, low grade fever, fatigue and red nodules under the skin. Monitor and advise your therapist if you have any concerns. • Risk of developing Post Inflammatory Hyperpigmentation. Presenting as darkened patches on skin due to increased inflammation in skin.SKIN NEEDLING CONSENT FORM I acknowledge this is an elective cosmetic procedure. I have been provided with adequate information and the opportunity to ask questions and seek clarification re- garding this treatment procedure and its alternatives including no treatment at all. The treatment procedure, its benefits and potential risks have been adequately explained and understood by me to my satisfaction. I have been given an individual treatment plan with pre and post care instructions and agree to follow these with the support of my therapist to the best of my ability or otherwise contact my therapist or doctor if I am unsure. Every precaution will be taken to prevent complications and although rare, they can sometimes occur. I am aware of and accept the risk of rare and unforeseen complications which may not have been discussed and may result from this treatment. I will notify my therapist immediately if any unexpected events occur. I have disclosed my full and complete medical history and discussed my realistic cosmetic expectations to the best of my abilities. I will notify my therapist of any changes in my health status during my series of treatments that can increase potential risks or reduce efficacy. MEDICATION AGREEMENT The procedure has been explained to me and all my questions answered to my satisfaction I am aware of the benefits of using the pre and post skin care products as directed by my therapist I understand there may be 12-72 hours of “downtime” (redness, puffiness, sensitivity) after each Skin Needling procedure I am aware that a complete series of at least 4 treatments is recommended to achieve the best result. I consent to my photo being taken and stored electronically. I consent to my photograph being taken for use of before and after examples in marketing for Earth and Skin Pty Ltd. I have answered the client consent form truthfully and have disclosed all medical history and medications to the best of my knowledge. I am aware that a $50 Consultation with my skin therapist is required prior to starting Skin Needling and that this fee is redeemable in product from our Spa Retail. This fee is applicable even in the unlikely event that I am not a candidate for Skin Needling Full Name SignatureDate MM slash DD slash YYYY RISKS ASSOCIATEDHiddenEven though the risk of complication is extremely low, the following can occur: (Please Tick) Pigment changes (light or dark spots on the skin) lasting 1-6 months. Freckles may temporarily or permanently disappear in treated areas. Other potential risks include crusting, itching, pain, bruising, pimple-like bumps, dry skin, hypopigmentation (lightening of the skin), hyperpigmentation (darkening of the skin), blistering, burns, infection, scabbing, swelling, a very small risk of scarring and a failure to achieve the desired result Allergic or delayed inflammatory reactions can develop. A test patch is performed to ascertain reaction of the skin Prior to initiation of treatment, any pigmented lesions should be correctly identified by a physician to be benign. A medical certifi- cate to this effect is required I consent to photographs taken to evaluate effectiveness. Photographs revealing my identity will not be used without consent I understand the sensation of Skin Needling is sometimes uncomfortable and feels prickly and there might be a mild sun burn sensation after treatment I am aged 18 years or over (otherwise parent or guardian to sign) I will advise ............................................................. of any changes that occur during my treatment that can increase potential risks or reduce efficacy I also understand that there will be no refund for any performed services. HiddenIn relation to my initial and all subsequent treatments I advise that: (Please Tick) I have not had unprotected sun exposure (including tanning beds and fake tan creams) in the last 2 weeks I have no history of seizures and I have disclosed all known allergies (e.g. Latex, etc) I am not taking medications causing photosensitivity (prescrip- tion/non-prescription) eg. St John’s Wort, Anti-coagulants, etc I do not have a history of keloid & hypertrophic scar formation I do not have active infections/Immunosuppression I do not have open lesions in the areas to be treated I do not have Herpes I or II – in the areas to be treated I have not used Tretinoin (Retin –A) within the last 2 weeks I have not had Laser Resurfacing within the last 6 months I have not had a Chemical Peel – within the last 4 weeks I have not used Oral isotretinoin/Accutane – within the last 6 months I have advised my clinician if I am diabetic I am not pregnant, breastfeeding and not taking any medication, which may affect treatment outcomes I have received the Pre- and Post-Care Information Sheet I agree to adhere to all these recommendationsI have read all of the above and had all my questions satisfactorily answered. Note: Do not sign this form until you have read and understood all of the above.HiddenFull Name HiddenDate MM slash DD slash YYYY HiddenSignatureHiddenWitness: TREATMENT SERIES I certify that all the information given on the previous client form is still correct and true. I have not had any of the following: • Sun exposure or fake tanning products in the last 4 weeks • Stopped using “active” skincare and exfoliation 72 hours pre-treat- ment • Vaccinations in the last 8 weeks • Change in medication • Been under doctor’s care or supervision • Any surgery / injectable • Pregnancy/ trying to get pregnant or breastfeeding I will advise ............................................................. of any changes that occur during my treatment that can increase potential risks or reduce efficacy I also understand that there will be no refund for any performed services.Treatment 1HiddenSignatureHiddenClinician Witness HiddenDate MM slash DD slash YYYY Treatment 2HiddenSignatureHiddenClinician Witness HiddenDate MM slash DD slash YYYY Treatment 3HiddenSignatureHiddenClinician Witness HiddenDate MM slash DD slash YYYY Treatment 4HiddenSignatureHiddenClinician Witness HiddenDate MM slash DD slash YYYY Treatment 5HiddenSignatureHiddenClinician Witness HiddenDate MM slash DD slash YYYY Treatment 6HiddenSignatureHiddenClinician Witness HiddenDate MM slash DD slash YYYY Treatment 7HiddenSignatureHiddenClinician Witness HiddenDate MM slash DD slash YYYY Treatment 8HiddenSignatureHiddenClinician Witness HiddenDate MM slash DD slash YYYY Treatment 9HiddenSignatureHiddenClinician Witness HiddenDate MM slash DD slash YYYY Treatment 10HiddenSignatureHiddenClinician Witness HiddenDate MM slash DD slash YYYY Treatment 11HiddenSignatureHiddenClinician Witness HiddenDate MM slash DD slash YYYY Treatment 12HiddenSignatureHiddenClinician Witness HiddenDate MM slash DD slash YYYY