Welcome. Nanoneedling Intake & Consent Form Name * First Name Last Name Date Of Birth * Sex Female Male NB Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Would you like to learn more about skincare products and routines? Sure! No, thank you. Are you okay with Paige taking photos that could share for marketing purposes? OMG, of course! No, thank you. Emergency contact * Name and Phone number How did you hear about us? MEDICAL HISTORY Do you have or have you had any of the following conditions? If yes, please select them: Acne Arthritis Asthma Blood disorder Cancer Diabetes Eczema Epilepsy Fever blisters Heart condition Herpes Hepatitis High blood pressure HIV/AIDS Hyper pigmentation Hypo pigmentation Hysterectomy Immune disorders Insomnia Keloid scarring Low blood pressure Lupus Metal bone pins/plates Phlebitis, blood clots Seizure disorder Skin disease/lesions Seborrhea Thyroid condition Varicose veins Warts Any other condition: Have you in the last 3 months used Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products? * If yes, please describe Any known allergies? * List any medications you take regularly, including vitamins, herbal supplements, aspirin: * Have you ever used acne medication? * If yes, when? And which Drug? Have you received Botox, Restylane, or Collagen injections in the last 6 months? * If yes, please describe Have you had Nano Needling Treatment before? * If yes, please share when and how your skin reacted. Any recent surgery, including plastic surgery? If yes, explain Are you pregnant or trying to become pregnant? Yes No Have you ever had a facial treatment before? If yes, please explain What would you like to achieve from your treatment today? What is your current skin care routine? * What products are you currently using? * What is your skin type? Normal Oily Dry Combo Unsure Your exposure to the sun? Never Light Moderate Excessive How does your skin heal? Fast Slow Scars Pigments Skin Concerns Acne Blackheads Broken Capillaries Comedones Discoloration Dryness/Dull Skin Eczema Fine lines/Wrinkles Hyper pigmentation Hypo pigmentation Milia Oily Skin Psoriasis Redness Rosacea Sensitivity Sun Damage Sign & Read Consent * I have received a consultation with Registered Nurse/Esthetician/Skin Care Specialist and I consent to the treatment of Nano Skin Needling to be carried out upon myself. 1. I acknowledge that I have not used Accutane or any medication for the same purpose during the last 6 months. 2. 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. 3. 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. 4. I acknowledge that my skin may experience temporary irritation, tightness and redness. 5. I acknowledge that if I fail to use minimal sunscreen (SPF 30), I am more susceptible to sunburn, skin damage and hyperpigmentation. 6. 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. 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 Paige Ashley Aesthetics 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 🩷 You are beautiful! Thank you! 🩷 320 Kokanee LoopCle Elum, WA 98922 Follow forSpeical Offers!
