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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.

CONTRAINDICATIONS

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).

I Agree
I have no allergies to anything that I am aware of 

I Agree
I understand that I must verbally inform my esthetician of any concerns, use of medications (including pain medication) or medical conditions I have before receiving MicroChanneling.

I Agree
I am not under the influence of alcohol, drugs or any other substances.

I Agree
I release ProCell Therapies, and its subsidiaries and representatives and Sage Wellness Spa LLC and its subsidiaries and representatives of all claims for injury seen or unseen that may occur as a result of this procedure.

I Agree
I understand that no promise has been made to me as to the final result of the procedure.

I Agree
I have been given the opportunity to address all of my questions and concerns about the risk, hazards and aftercare for the procedure(s) that will be performed with my consent.

I hereby release ProCell Therapies and Sage Wellness Spa LLC and its subsidiaries and representatives from liability associated with my MicroChanneling Treatment.

[Signature]

[Date]

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Client's 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*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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 Date of Birth*
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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