Microchanneling Consent Form

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect.

I have already agreed to the Facial Consent Form.

  • I give permission to my skin esthetician to perform a microchanneling treatment

  • I agree to be truthful about my physical conditions, pregnancy, medications that I may be taking, and my current skin care regimen. I am also aware that my lifestyle, which if it includes smoking, outdoor exposure, tanning beds, alcohol consumption and/or recreational use of controlled substances, will effect and diminish the effectiveness and result of the microchanneling treatment.

  • Microchanneling devices intentionally create very superficial “micro-injuries” to the outermost layer of the skin (.25mm) inducing the healing process to create collagen production. Microchanneling has been shown to reduce the visibility of acne scars, fine lines, and wrinkles, diminish hyperpigmentation, and improve skin tone and texture, resulting in smoother, firmer, younger-looking skin. Microchanneling treatments are performed in a safe and precise manner with sterile devices and are normally completed within 30-60 minutes, depending on the selected area.

  • Although, the majority of patients do not experience any complications with microchanneling, it is important you understand that risks do exist. Microchanneling uses small stainless steel cones to deliver product to the stratum corneum. Because of this, it can lead to: infection, pigment/color change, scarring, pain, persistent redness, itching, and/or swelling, and/or an allergic reaction.

  • I understand that after the procedure the skin will be red with mild swelling, and might feel tight and sensitive to the touch. Although these symptoms may take 2-3 days to resolve completely, they will diminish significantly within a few hours after treatment.

  • I understand there are certain contraindications that would preclude me from receiving micro-needling treatments including:

    • Active acne

    • Active infection of any type (bacterial, viral, or fungal)

    • Cardiac disease/abnormalities

    • Collagen vascular disease

    • Eczema

    • Psoriasis

    • Dermatitis

    • Hemophilia/ bleeding disorders

    • Keloid/hypertrophic scaring

  • Pregnancy/lactation

  • Raised lesions (moles, warts, etc.)

  • Skin cancer

  • Sunburn

  • Tattoos

  • Telangiectasia/erythema

  • Uncontrolled diabetes

  • Vascular lesions (hemangiomas)

  • I understand that the use of Botox®, Juvederm®, Restylane®, and any other injectable must be disclosed prior to treatment. Microchanneling cannot be performed within 2 weeks of these treatments.

  • I understand that there are some contraindicated medications:

    • Blood thinner medications

    • Chemotherapy or radiation

    • Hormone replacement therapy

    • Recent use of some topical medication.

  • I understand that microchanneling is contraindicated within 72 hours of waxing, and within 2 weeks of a chemical peel.

  • I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.

  • I understand that I must wear sunscreen after a microchanneling treatment and avoid the sun for 3 days

  • In the event of any questions or concerns, I will consult my esthetician immediately. I understand the potential risks and complications and I have chosen to proceed with the treatment after careful consideration of both known and unknown risks, complications, and limitations. I will hold the esthetician from any liability that may result from this treatment. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.