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Microneedling Consent Form

I have received a consolation with an Aesthetician and I consent to the treatment of Microneedling to be carried out upon myself. 

I acknowledge that I have not used Accutane or any medications for the same purpose within the last 6 months.


I acknowledge that if I have ever had a cold sore or fever blister, I have informed the practitioner and should consider taking an anti-viral medication to help avoid a possible breakout. The medication should be used two days before, and two days after any aggressive facial exfoliation treatment.


I acknowledge that there is no guarantee that dark discoloration of the skin will be reduced or fade. Pigmentation may improve or darken with successive treatments. I acknowledge the need for proper skin care home regimen.


I acknowledge that my skin may experience temporary irritation, tightness and redness for 2-4 days following treatment.


I acknowledge that if I fail to use minimal sunscreen (SPF 30), I am more susceptible to sunburn, skin damage and hyperpigmentation.


I acknowledge that this treatment strictly an elective cosmetic procedure and that no medical claims have been expressed or implied. 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.


I understand my obligation to follow the instructions closely and visit the office as directed. I certify that I have read the above consent and fully understand it. I have been given ample opportunity for discussion and all of my questions have been answered to my satisfaction. I also agree to hold harmless and release from any liability Restorative Skincare Atlanta, LLC known or unknown that may arise as a result of any treatment that I receive. 

Date: October 31, 2025

First Participant's Name
First Name*
Middle 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 Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
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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*
Middle 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 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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