Prior to receiving treatment, please reveal any conditions that may have an effect on this treatment. If you are unsure of any details including personal requirements and potential complications, please discuss with your practitioner.
I confirm that the information I have supplied is correct to the best of my knowledge and that there is no other pertinent medical information I need to disclose.

I confirm that I understands the risks and conditions associated with Derma Roller / Micro Needling treatment and that it is an elective procedure.

The Micro needling treatment is typically used for skin rejuvenation and improvement of scars. This treatment uses a derma roller or micro needling medical device to create micro needle punctures that cause mild trauma to the skin's surface to stimulate the natural production of new collagen and elastin.

Reactions from treatment include: skin redness and flushing, tightness, itching, tenderness, stinging, swelling and some pinpoint bleeding.

Effects will usually typically resolve within hours and many people are able to return to their normal activities the same or next day. Some people may react differently and may experience these reactions for longer. However, these reactions are temporary and typically resolve within 3-4 days as the skin returns to normal.

There is a small risk of side effects causing the skin to turn very red, blister, swell, peel and later scab and crust. In severe cases infection and ulceration may result, although this is not expected to occur due to the sterility of the derma roller/ micro needling device and the minimally invasive nature of the micro-medical needles.

Micro needle Therapy procedure may cause areas of bruising although this would not normally be expected to occur, the eye contour being the area at most risk. Any such bruising will be temporary. If you are taking any medication or dietary supplements that can affect platelet function and bleeding time, the severity and period of bruising can be extended, also the presence of petechiae (small red or purple spots beneath the skin) may be observed.

There is a small risk that hyperpigmentation of the skin can occur after the procedure, although this is not normally expected as the epidermis of the skin is not removed as a result of the procedure. Failure to follow the advice detailed below can increase this risk.

I have been given the following post treatment advice:

Refrain from touching the skin with your hands until the pores have had chance to close. DO NOT PICK OR PULL THE SKIN. Any redness should subside over a 24-36 hour period.

Gently wash the treated areas on the same day, but do not rub or massage the face for 2 weeks. Cleanse using a mild cleanser. It is recommended that the use of soaps, other than those recommended by your practitioner, on the treated skin area is restricted until the redness subsides and where possible lukewarm water and/or gentle skin cleansers are used for cleansing. Do not scrub. Pat to dry only with a clean towel.

Use of intensive moisturiser is advised for at least a week as your skin may feel drier or tighter after your treatment - this is quite normal.

Use of intensive moisturiser is advised for at least a week as your skin may feel drier or tighter after your treatment - this is quite normal.

Avoid facial products containing fragrance for 3-5 days after treatment as these may irritate the skin.

Make up can be applied once the skin has settled, but ensure all brushes and sponges have been cleaned.

Refrain from extreme temperatures such as intensive sun light, saunas, sunbed, steam bath for a period of at least 2 weeks after treatment.

Apply a sunscreen with an SPF30+ (such as the CLINICCARE Sun Shield Silky Cream SPF30) on a daily basis and with regular applications for a period of at least 2 weeks.

Avoid electrolysis, waxing, bleaching (face), depilatory creams, laser hair removal for at least 72 hours.

Avoid strong chlorinated water (swimming or cleaning) for approximately 14 days.

Please report any concerns to your practitioner as soon as possible.

I confirm that I understand the risks and conditions accociated with this treatment and that it is an elective medical- cosmetic treatment.

I confirm that the medical history and medication details that I have supplied are complete and correct and that there is no other medical information I need to disclose.

I understand that withholding any medical information may be detrimental to my health and safety during the treatment in which I agree to undertake.

If there is any change in my medical history, it is my responsibility to advise the practitioner before further treatments are carried out.

I understand that there are certain contraindications that would preclude me from receiving treatment including an active bacterial, viral, fungal, or herpetic infection, raised moles or warts, active acne, rosacea, facial cancers, history of radiation therapy within the application area, a history of abnormal scarring, keloids, atrophic skin, autoimmune disorders, haemophiliac, diabetes, taking anticoagulants, pregnant or breastfeeding.

I confirm that I understand the risks and conditions associated with the treatment. These have been fully explained to me and I have had the opportunity to ask any questions and these have been answered to my satisfaction. Development of any reactions must be reported to the practitioner as soon as possible.

I accept and understand that there are no written, implied, or verbal guarantees as to the anticipated results of this treatment and that the effects of treatment will vary with some patients than with others and that the goal of this treatment is improvement, not perfection.

I may require a series of treatments, normally with at least 3-6 weeks between procedures, to achieve the maximum cosmetic result.

I have been given post treatment advice and I understand and agree to follow all the care instructions carefully to minimise the risk of side effects.

I confirm that I have been allowed sufficient time to make a carefully considered decision.

I consent to the taking of (pre and post-treatment) photographs to monitor treatment effects. Complete patient confidentiality will be maintained at all times.

I also consent / do not consent (please circle as applicable) to these photographs being used for:

I understand that I am free to withdraw my consent at any time.

I have read the above consent, and I confirm that by signing this form I consent to undergo treatment and I take responsibility to inform of any change in my medical history.

Facial Treatment Patient Notes