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Microneedling Consent Form - Vixen Esthetics

Micro-Needling Consent Form

Micro-needling is based on the skin’s natural ability to repair itself. Micro-needling treatments create superficial “micro-channels” to the outermost layer of the skin, inducing the healing process including new collagen production. Micro-needling has been shown to reduce the visibility of acne scars, fine lines, and wrinkles, diminish hyperpigmentation, and improve skin tone and texture.

 I hereby authorize and direct the associates or assistants of Vixen Esthetics as medically advised by Dr. David Sneed perform my Micro-needling treatments.  


 

 I understand possible side effects include and are not limited to: slight or extreme redness, histamine reaction, swelling, stinging, itchy, tender, dry or flaking skin. In rare instances, hyperpigmentation/hypopigmentation, scarring, or infection can occur.  


I UNDERSTAND THAT I SHOULD ONLY APPLY PRODUCTS RECOMMEDED BY MY CLINICIAN POST TREATMENT.  


I undertstand that Improvement of the skin may also be accomplished by other treatments. Options include laser skin surface treatments, chemical peels, microdermabrasion, and facials. Other options not mentioned here may exist. Risk and potential complications are associated with alternative treatments.  


I understand that Most side effects will gradually diminish over time as healing may take several days. Notify your clinician if any side effects cause extreme discomfort or any unexpected problems occur immediately.  


I am not under the influence of Alcohol/Drugs at the time of this procedure.  


I have avoided the following products/procedures THREE DAYS prior to treatment:

Topical prescriptions including but not limited to Retin-A, Tretinoin, Differin, Tazorac


Abrasive scrubs or other exfoliating products


 

I have not had any cosmetic injections within the last TWO WEEKS



Notify your technician PRIOR TO SIGNING THIS CONSENT if any of the following apply to you:

 Cold sores(or history), warts, open skin lesions, sunburn, extreme sensitivity, dermatitis, rosacea

 Blood thinning medications 

 Accutane or generic within the past year

 Pregnant or breastfeeding

 Received chemotherapy or radiation therapy

 Collagen Vascular Disease

 Eczema, Psoriasis, or Dermatitis

 Hemophilia / bleeding disorders

 Keloid/hypertrophic scaring

 History of autoimmune disease or any condition that may weaken you immune system

I am undergoing treatment of my own free will. I agree that this procedure is being performed for cosmetic reasons and that no guarantee can be made as to the exact results of this procedure. I understand that every precaution will be taken to prevent complications and that complications from this procedure are rare, they can and sometimes do occur.

I Agree

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. Multiple treatments may be necessary to achieve optimal results.

I Agree

Although rare, allergic reaction to the pigment and procedure may occur.

I Agree

ACKNOWLEDGMENT

BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS MICRONEEDLING CONSENT FORM AND THAT THE DISCLOSURES REFERRED TO HEREIN WERE MADE TO ME.

April 29, 2026

First Participant's Name
First Name*
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
How did you hear about us? *
Are you pregnant or breastfeeding?*
No
Yes
Have you been on Accutane or generic alternatives within the last 12 months?*
No
Yes
Have you followed all prepare instructions as provided by your clinician?*
No
Yes
Will you adhere to following aftercare as provided by your clinician? (Failure to follow aftercare can result in undesired results)*
No
Yes
Do you have any other health conditions that you need to make your clinician aware of? Including allergies, sensitivities to certain products etc.*
No
Yes
If you answered "yes" to the above question, please list these health conditions, sensitivities, or allergies.
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
How did you hear about us? *
Are you pregnant or breastfeeding?*
No
Yes
Have you been on Accutane or generic alternatives within the last 12 months?*
No
Yes
Have you followed all prepare instructions as provided by your clinician?*
No
Yes
Will you adhere to following aftercare as provided by your clinician? (Failure to follow aftercare can result in undesired results)*
No
Yes
Do you have any other health conditions that you need to make your clinician aware of? Including allergies, sensitivities to certain products etc.*
No
Yes
If you answered "yes" to the above question, please list these health conditions, sensitivities, or allergies.
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
How did you hear about us? *
Are you pregnant or breastfeeding?*
No
Yes
Have you been on Accutane or generic alternatives within the last 12 months?*
No
Yes
Have you followed all prepare instructions as provided by your clinician?*
No
Yes
Will you adhere to following aftercare as provided by your clinician? (Failure to follow aftercare can result in undesired results)*
No
Yes
Do you have any other health conditions that you need to make your clinician aware of? Including allergies, sensitivities to certain products etc.*
No
Yes
If you answered "yes" to the above question, please list these health conditions, sensitivities, or allergies.
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
How did you hear about us? *
Are you pregnant or breastfeeding?*
No
Yes
Have you been on Accutane or generic alternatives within the last 12 months?*
No
Yes
Have you followed all prepare instructions as provided by your clinician?*
No
Yes
Will you adhere to following aftercare as provided by your clinician? (Failure to follow aftercare can result in undesired results)*
No
Yes
Do you have any other health conditions that you need to make your clinician aware of? Including allergies, sensitivities to certain products etc.*
No
Yes
If you answered "yes" to the above question, please list these health conditions, sensitivities, or allergies.
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
How did you hear about us? *
Are you pregnant or breastfeeding?*
No
Yes
Have you been on Accutane or generic alternatives within the last 12 months?*
No
Yes
Have you followed all prepare instructions as provided by your clinician?*
No
Yes
Will you adhere to following aftercare as provided by your clinician? (Failure to follow aftercare can result in undesired results)*
No
Yes
Do you have any other health conditions that you need to make your clinician aware of? Including allergies, sensitivities to certain products etc.*
No
Yes
If you answered "yes" to the above question, please list these health conditions, sensitivities, or allergies.
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
How did you hear about us? *
Are you pregnant or breastfeeding?*
No
Yes
Have you been on Accutane or generic alternatives within the last 12 months?*
No
Yes
Have you followed all prepare instructions as provided by your clinician?*
No
Yes
Will you adhere to following aftercare as provided by your clinician? (Failure to follow aftercare can result in undesired results)*
No
Yes
Do you have any other health conditions that you need to make your clinician aware of? Including allergies, sensitivities to certain products etc.*
No
Yes
If you answered "yes" to the above question, please list these health conditions, sensitivities, or allergies.
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
How did you hear about us? *
Are you pregnant or breastfeeding?*
No
Yes
Have you been on Accutane or generic alternatives within the last 12 months?*
No
Yes
Have you followed all prepare instructions as provided by your clinician?*
No
Yes
Will you adhere to following aftercare as provided by your clinician? (Failure to follow aftercare can result in undesired results)*
No
Yes
Do you have any other health conditions that you need to make your clinician aware of? Including allergies, sensitivities to certain products etc.*
No
Yes
If you answered "yes" to the above question, please list these health conditions, sensitivities, or allergies.
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
How did you hear about us? *
Are you pregnant or breastfeeding?*
No
Yes
Have you been on Accutane or generic alternatives within the last 12 months?*
No
Yes
Have you followed all prepare instructions as provided by your clinician?*
No
Yes
Will you adhere to following aftercare as provided by your clinician? (Failure to follow aftercare can result in undesired results)*
No
Yes
Do you have any other health conditions that you need to make your clinician aware of? Including allergies, sensitivities to certain products etc.*
No
Yes
If you answered "yes" to the above question, please list these health conditions, sensitivities, or allergies.
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
How did you hear about us? *
Are you pregnant or breastfeeding?*
No
Yes
Have you been on Accutane or generic alternatives within the last 12 months?*
No
Yes
Have you followed all prepare instructions as provided by your clinician?*
No
Yes
Will you adhere to following aftercare as provided by your clinician? (Failure to follow aftercare can result in undesired results)*
No
Yes
Do you have any other health conditions that you need to make your clinician aware of? Including allergies, sensitivities to certain products etc.*
No
Yes
If you answered "yes" to the above question, please list these health conditions, sensitivities, or allergies.
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
How did you hear about us? *
Are you pregnant or breastfeeding?*
No
Yes
Have you been on Accutane or generic alternatives within the last 12 months?*
No
Yes
Have you followed all prepare instructions as provided by your clinician?*
No
Yes
Will you adhere to following aftercare as provided by your clinician? (Failure to follow aftercare can result in undesired results)*
No
Yes
Do you have any other health conditions that you need to make your clinician aware of? Including allergies, sensitivities to certain products etc.*
No
Yes
If you answered "yes" to the above question, please list these health conditions, sensitivities, or allergies.
Parent or Guardian's Email Address
Email*
Confirm Email*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card
Driver's License / ID Card Number*
Issuing State*
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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 Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
How did you hear about us? *
Are you pregnant or breastfeeding?*
No
Yes
Have you been on Accutane or generic alternatives within the last 12 months?*
No
Yes
Have you followed all prepare instructions as provided by your clinician?*
No
Yes
Will you adhere to following aftercare as provided by your clinician? (Failure to follow aftercare can result in undesired results)*
No
Yes
Do you have any other health conditions that you need to make your clinician aware of? Including allergies, sensitivities to certain products etc.*
No
Yes
If you answered "yes" to the above question, please list these health conditions, sensitivities, or allergies.
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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