Procell Microchanneling Consent Form MicroChanneling is an elective procedure for cosmetic purposes only. I have had the opportunity to ask questions and understand the nature, goals, limitations and possible complications of this treatment. I have had the opportunity to discuss alternative forms of treatment and understand that results may vary. While MicroChanneling treatments are safe and effective for most women and men, there are some people who will not be good candidates for treatments. Here is a general contraindication: • Pregnancy – if you are pregnant or nursing you are advised to not receive any MicroChanneling treatments. To date there have been no studies conducted to see what effects these treatments may have on the unborn child, but as a general rule, pregnant women should stay away from any type of cosmetic/elective procedures. • Diabetes - unstable diabetes patients should not be treated due to healing problems. • Active Herpes Simplex in the treatment area - treatment is possible once the outbreak is healed, however it may be advisable to take prescription strength antiviral medication to keep this condition in remission during the treatment series. • Dry skin - if your skin is overly dry, you will need to start moisturizing and ensure the condition is under control prior to undergoing any treatment. • Any active inflammatory skin condition e.g. eczema, psoriasis, infection, rash or any type of dermatitis at the treatment site (because it may aggravate the condition). Please read and agree to the following: * I have no allergies to anything that I am aware of. I understand that I must verbally inform my technician of any concerns, use of medication (including pain medications) or medical conditions I have before receiving MicroChanneling. I am not under the influence of alcohol, drugs or any other substances. I release ProCell Therapies, and its subsidiaries and representatives of all claims for injury seen or unseen that may occur as a result of this procedure. I understand that no promise has been made to me as to the final result of the procedure. I have been given the opportunity to address all of my questions and concerns about the risks, hazards and aftercare for the procedure(s) that will be performed with my consent. I understand that I cannot apply any products for at least 90 minutes post treatment. This includes sunscreens, moisturizers, and all makeup. I understand that I need to avoid direct sunlight for the remainder of the day. I hearby release Procell Therapies and GLO Aesthetics from liability associated with my Microchanneling treatment. Name * First Name Last Name Phone * (###) ### #### Email * Signature * Date * MM DD YYYY Thank you!
