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Kino by Kimie

4347 Rice Street Suite 208

 Lihue, HI 96766

   Collagen Induction Therapy / Micro-needling Consent for Treatment


I,

 hereby give my consent to undergo Collagen Induction Therapy (Micro-needling) treatments provided by licensed professional.


I understand this technique involves the introduction of fine needles through the skin. The purpose is to create micro-channels in the skin allowing the infusion of active ingredients (such growth factors and hyaluronic acid) to penetrate deeply and effectively into the dermis, nourishing the skin and stimulating the regrowth of collagen. A series of 4 to 6 treatments are recommended and the frequency will depend on the intensity and depth of the needle.


I understand that the treatments require many small injections on the area(s) to be treated. I understand that the administration of numbing creams may be used if deemed needed.


Micro-needling is not suitable in these circumstances:
⬥ Have used Accutane (isotretinoin) within the last year.
⬥ Have open wounds, cuts or abrasions on the skin
⬥ Have had radiation treatment to the skin within the last year
⬥ Have any kind of current skin infection, condition, herpes simplex in the area to be treated
⬥ Are pregnant or breastfeeding
⬥ Have any history of keloid or hypertrophic scars or poor wound healing


I understand that there are some risks with any procedure. The following are possible reactions with Micro-needling: temporary bruising, skin discomfort during injections, redness or swelling, lightening or darkening of the skin, itching and burning. Skin infection is a possibility any time an injection or surgical procedure is done. Side effects are most of the time temporary and typically resolve within 3 days. Total healing time depends on the depth of the treatment, skin type, and skin condition, and some patients may heal completely in 24 hours.
By my signature I acknowledge that no promises or guarantees have been made to me as a result of the treatment. I accept that Kino by Kimie has a no refund policy on all services, service packages, gift cards and products. If there are any problems, Kino by Kimie must be contacted within 2 days of the purchase/service. If work/product is determined to be unsatisfactory, the technician will then use their discretion to resolve the issue.
 
  I am aware that the results achieved by this treatment may vary from person to person. Some patients typically notice an immediate glow, but visible improvement will take about 2-4 weeks and can continue for up to 6 months.
I have read potential risks have been explained to me and I accept them.
I hereby give my voluntary consent to have this treatment performed on me.

 


 


Collagen Induction Therapy / Micro-needling Pre-Treatment Instructions Preparing Skin​:
1. Use agreed upon gentle cleanser
2. Avoid direct sun exposure or tanning bed at least 4 weeks prior to treatment and during treatment process.
3. Do not exercise the day of or for 48 hours after the induction treatment.
4. Avoid caffeine containing food or beverages day of treatment.
5. Avoid medications such as: Aleve, Advil, cold remedies, Vitamin E or aspirin 5 days prior to treatment.
6. Avoid Retin-A, chemical peels, injectable fillers or Botox 2 weeks prior to treatment.
7. Discontinue Hydroquinone, AHA’s, BHA’s, Benzoyl peroxide, and any other possible irritants 3-5 days prior to treatment.
8. Use a sunblock with an SPF 30+ with UVA/UVB Broad Spectrum protection.
9. Apply topical anesthetic cream 1 hour prior to procedure and reapply if necessary.
10. Day of treatment wear comfortable clothing. Your top should button or zip rather than pull over the head.
11. Notify medical Aesthetician if you get cold sores. You will require an antiviral prescription to avoid any breakout after treatments.
12. If you have open cuts, wounds, abrasions or during active acne or cold sores breakouts, we cannot perform the procedure.
  13. Eat a healthy diet, whole food vitamins and minerals. It is also advisable to take 1000 mg of vitamin C and 2000 iu. of vitamin D3. This ensures an increase in vitamins internally and externally and will greatly aid in the healing process. Liquid and topical hyaluronic acid is recommended to retain moisture in the skin and prevent dehydration.
14. Drink 8 glasses of water/non-caloric fluids per day.



Collagen Induction Therapy / Micro-needling Post-Treatment Instructions

What to be expected:
⬥ Day 1​: Skin will be erythematous and flushed after treatment, depending on the intensity of the
treatment. Pinpoint bleeding may occur. Do not apply makeup for at least 12 hours.
⬥ Day 2​: A red or pink hue persists like moderate sunburn. Swelling and slight bruising may be
more noticeable on the second day. Minor scratches may be visible. Apply moisturizer as
needed.
⬥ Day 3​: Skin can be pink or normal color. Swelling subsides. The skin can feel dry or feel tight. A
slight outbreak of acne or milia (tiny white bumps) is possible. Light peeling usually occurs in about three days and will be replaced with brand new skin.


Home Care:
1. Wash the treated area with a gentle cream cleanser using your fingers only. Gently massage the face with lukewarm water. Remove serum and other debris such as dried blood. Do not scrub, use a washcloth or a Clarisonic brush. Cleanse treated area twice a day. Do not use exfoliating products for 72 hours.
2. Keep skin hydrated with post-care products provided by the professional who performed your treatment. It is very important to keep the skin hydrated the days following your treatment. New cell regeneration requires at least 6-8 8 oz. glasses of water a day (if you already drink that- increase by 2 glasses)
3. Cool compresses may be applied following treatment for comfort. If neck or décolletage are treated, the redness might last slightly longer.
4. Do not exercise for 24 hours after treatment and avoid strenuous exercise for two to three days after treatment until redness completely subsides.
5. Avoid saunas, steam rooms, hot baths or showers until redness is gone.
6. Continue to avoid sun exposure to the treatment areas and apply a broad spectrum sunblock with
SPF minimum of 30. Apply it at least 30 minutes prior to sun exposure and repeat after every two
hours of sun exposure.
7. After 2-5 days patients can return to regular skin care products or as soon as it is comfortable to do
so. Mineral makeup may be applied the following day.
8. Avoid waxing, facials, Botox, injectable fillers or any other skin care treatment 10 days after
treatment.

  9. If skin becomes painful, swollen, red or inflamed, please notify your skin care professional, as this may represent an infection or allergic reaction that may require treatment.


 

   

First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Consent
Do you consent to being photographed/ recorded for educational and social media purposes?*
No
Yes
I understand that I must return 5-6 weeks after my last treatment for progress photos and reports*
No
Yes
I understand that all CIT and chemical peel packages purchased through Kino by Kimie expire within 365 days of the date purchase and it is my responsibility to schedule all appointments and follow up appointments*
No
Yes
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Second Clients Consent
Do you consent to being photographed/ recorded for educational and social media purposes?*
No
Yes
I understand that I must return 5-6 weeks after my last treatment for progress photos and reports*
No
Yes
I understand that all CIT and chemical peel packages purchased through Kino by Kimie expire within 365 days of the date purchase and it is my responsibility to schedule all appointments and follow up appointments*
No
Yes
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Third Clients Consent
Do you consent to being photographed/ recorded for educational and social media purposes?*
No
Yes
I understand that I must return 5-6 weeks after my last treatment for progress photos and reports*
No
Yes
I understand that all CIT and chemical peel packages purchased through Kino by Kimie expire within 365 days of the date purchase and it is my responsibility to schedule all appointments and follow up appointments*
No
Yes
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fourth Clients Consent
Do you consent to being photographed/ recorded for educational and social media purposes?*
No
Yes
I understand that I must return 5-6 weeks after my last treatment for progress photos and reports*
No
Yes
I understand that all CIT and chemical peel packages purchased through Kino by Kimie expire within 365 days of the date purchase and it is my responsibility to schedule all appointments and follow up appointments*
No
Yes
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Fifth Clients Consent
Do you consent to being photographed/ recorded for educational and social media purposes?*
No
Yes
I understand that I must return 5-6 weeks after my last treatment for progress photos and reports*
No
Yes
I understand that all CIT and chemical peel packages purchased through Kino by Kimie expire within 365 days of the date purchase and it is my responsibility to schedule all appointments and follow up appointments*
No
Yes
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Sixth Clients Consent
Do you consent to being photographed/ recorded for educational and social media purposes?*
No
Yes
I understand that I must return 5-6 weeks after my last treatment for progress photos and reports*
No
Yes
I understand that all CIT and chemical peel packages purchased through Kino by Kimie expire within 365 days of the date purchase and it is my responsibility to schedule all appointments and follow up appointments*
No
Yes
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Seventh Clients Consent
Do you consent to being photographed/ recorded for educational and social media purposes?*
No
Yes
I understand that I must return 5-6 weeks after my last treatment for progress photos and reports*
No
Yes
I understand that all CIT and chemical peel packages purchased through Kino by Kimie expire within 365 days of the date purchase and it is my responsibility to schedule all appointments and follow up appointments*
No
Yes
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Eighth Clients Consent
Do you consent to being photographed/ recorded for educational and social media purposes?*
No
Yes
I understand that I must return 5-6 weeks after my last treatment for progress photos and reports*
No
Yes
I understand that all CIT and chemical peel packages purchased through Kino by Kimie expire within 365 days of the date purchase and it is my responsibility to schedule all appointments and follow up appointments*
No
Yes
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Ninth Clients Consent
Do you consent to being photographed/ recorded for educational and social media purposes?*
No
Yes
I understand that I must return 5-6 weeks after my last treatment for progress photos and reports*
No
Yes
I understand that all CIT and chemical peel packages purchased through Kino by Kimie expire within 365 days of the date purchase and it is my responsibility to schedule all appointments and follow up appointments*
No
Yes
Tenth Clients Name

First Name*

Last Name*
Tenth Clients Date of Birth*
Tenth Clients Consent
Do you consent to being photographed/ recorded for educational and social media purposes?*
No
Yes
I understand that I must return 5-6 weeks after my last treatment for progress photos and reports*
No
Yes
I understand that all CIT and chemical peel packages purchased through Kino by Kimie expire within 365 days of the date purchase and it is my responsibility to schedule all appointments and follow up appointments*
No
Yes
Clients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Consent
Do you consent to being photographed/ recorded for educational and social media purposes?*
No
Yes
I understand that I must return 5-6 weeks after my last treatment for progress photos and reports*
No
Yes
I understand that all CIT and chemical peel packages purchased through Kino by Kimie expire within 365 days of the date purchase and it is my responsibility to schedule all appointments and follow up appointments*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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