Philings Consent Form (Microneedling) Please enable JavaScript in your browser to complete this form.1Personal Info2Medical Info3Agreement & Treatment InfoCONSENT FORM FOR FACIAL SKIN TREATMENT USING PHILINGS TECHNIQUE Between Practitioner/Technician *FirstLast& Client Name *FirstLastEmail *Next1. STATEMENT Client will be informed in detail about the facial skin treatment using philings technique by a practitioner. Practitioner/technician is obligated to perform treatment in strict compliance with all hygiene and health protection measures. 2. CLIENT HEALTH CONDITION QUESTIONNAIRE In order to perform the facial skin treatment in a safe manner, please answer the following health questions truthfully. This information is confidential and it shall also be handled in that way. It will not be shared with any third party. 1. Do you suffer from any blood disorder (thrombosis, hemophilia, anemia etc)? *YesNo2. Do you have diabetes? *YesNo3. Do you have any type of hepatitis (A, 8, C, D, E, F)? *YesNo4. Are you hiv+? *YesNo5. Do you suffer from any skin condition (rosacea, impetigo, erysipelas, lupus, scleroderma or any other disease)? *YesNo6. Do you have a history of skin sensitivity (eczema or atopic dermatitis)? *YesNo7. Do you have allergy to medications, food, metals, makeup or any other Compound? *YesNo8. Do you have any autoimmune disorder? *YesNo9. Do you suffer from any acute or chronic infectious disease? *YesNo10. Are you prone to cold sores (herpes) or fever blisters? *YesNo11. Do you have epilepsy or any other seizure-related condition? *YesNo12. Do you have any heart-related problems? *YesNo13. Are you pregnant? *YesNo14. Are you breastfeeding? *YesNo15. Do you take any prescribed medications on daily basis (e.g. aspirin, anticoagulants etc.)? *YesNo16. Are you wearing a pacemaker? *YesNo17. Do you have any problems healing from wounds? *YesNo18. Do you tend to develop keloid or hypertrophic scars? *YesNo19. Have you consumed drugs or alcohol in the past 24 hours? *YesNo20. Did you undergo surgery or any other medical procedures in the last 14 days? *YesNo21. Have you had a botox injection within 6 months? *YesNo22. Have you had a laser or chemical peels within 6 months? *YesNo23. Have you ever had PMLJ or any cosmetic treatment? *YesNo24. Do you routinely use retinol-a, glycol or other exfoliating products? *YesNo25. Do you wear contact lenses? *YesNo26. Is your skin oily? *YesNo27. Do you have your period at the moment of treatment? *YesNo28. Do you have tendency to develop dark spots on the skin from wounds or sun? *YesNo29. Do you scar easily from minor skin injuries? *YesNo30. Do you bleed excessively from minor cuts? *YesNo31. Do you have prosthetic implants? *YesNo32. If you had PMLJ or any other cosmetic treatment did you have any problems with healing after they were applied? *YesNo33. Do you personally have any history of cancer? *YesNo34. Are you currently undergoing radiation or chemotherapy treatment? *YesNo35. Are you now or have you ever been on the acne treatment accutane? *YesNo36. Do you have any medical condition that has resulted in a medical professional requiring you to pre-medicate with an antibiotic prior to a dental or other Invasive procedure? *YesNoIf you answered “YES” to ANY questions above, use the space below or separate paper to provide an explanation. Correlate your explanation to a specific question number. A "YES" answer does not indicate you are not an acceptable candidate for cosmetic procedure. It may simply be information that is valuable to practitioner/technician as each person's body is unique or it may indicate that based on any health condition that affect healing, it would be advisable or required for you to consult with your physician before proceeding. If this form has not referred a medical condition you have please list it below. Additional Medical ConditionsPreviousNext3. CONTRACTUAL OBLIGATIONS I agree on photo taking of my face and using the photos for advertising purposes. *YesNo4. WARRANTY The client hereby release any and all persons representing the salon for all claims, demands, damages, actions and cause of action arising out of performance of the services. Practitioner/technician accepts liability in compliance with the legal measures and regulations in the case of negligence or carelessness or intentionally or negligently caused injuries or threat to life, body and health. This information is confidential and it shall also be handled in that way. It will not be shared with any third party. 5. EXPLANATION The client is informed in detail about specific risks of facial skin treatment using philings technique. The following risks are specifically explained to the client: During the treatment, despite the staff expertise and all the precautionary measures, the injury is possible. Despite the application of the most advanced and the top quality products, allergic reaction is possible but rare. The client is informed about this and he/she assumes liability. During and after the treatment temporary swelling, redness and/or itching may occur. Experience tells us that these symptoms are temporary. MICRONEEDLING After the procedure, the skin will be red and flushed in a similar way to moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on the area being treated. These effects will diminish greatly a few hours following treatment and within the next 24 hours the skin will be completely healed. After 3 days most visible erythema will be absolved. The results of applied treatment can be different due to differences in the skin quality, thus there is no warranty for the treatment success. To achieve desired results, it usually takes up to 3 treatments, with 2 weeks gap between each of them. The results last from 4 to 6 months. PHI-ION Clusters of yellowish spots up to 0.2 mm in diameter will appear in the treated area and remain visible up to 5 days. Eye lids may get swollen and become red after the treatment and the client may feel tingling. All these side effects should disappear within 7 to 10 days. Proper aftercare product application is of great importance. One treatment is usually enough to achieve the desired results. After 1 month, on check-up appointment, the practitioner/technician determines if an additional treatment is necessary. The results are expected to last for at least 9 months. Micro needling as well as plasma therapy always leads to the skin injury. Therefore, it is important to carefully and gently nurture your skin after the treatment to allow healing without complications. Inadequate after care procedure in healing phase of the skin can lead to poor results and practitioner and all persons representing the salon cannot be liable for it. IN THE NEXT 7 DAYS THE CLIENT IS REQUIRED TO PAY ATTENTION TO THE FOLLOWING: Do not wash your face at least 5 hours, optimally 12 hours, after the treatment to ensure optimal effect of PhiFace after treatment mask. Within the next 3 days after the treatment, a special kind of after care products (PhiSoothing Cream and Ultimate Skin Coctail) to be applied according to detailed instructions for use. Please do not use any other creams except the ones provided to you in order to prevent possible infections or allergic reactions. Do not apply makeup on the facial skin including eye lids for 48 hours after the treatment. In the first week after the treatment avoid public bathing, sunbathing, tanning salon, sauna, beauty treatments and intense training accompanied by sweating (sport activities), contact with the dust (household chores, etc. ). Two weeks after the treatment do not use botox as well as dermal fillers. PhiLings palette treatments can be safely performed 3 weeks after the treatment with botox or implantation of dermal fillers. Practitioner and all other persons representing the salon cannot be liable in case of improper post-treatment care. 6. COMPETENCE I confirm that I have read and understood the contents of each paragraph above. I have received no unrealistic warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedures. *YesI acknowledge by signing this consent form, I have been given the full opportunity to ask any and all questions about procedures and process from the practitioner/technician and/or his/her associates. I received a clear and understandable response to all of my questions. *YesThe treatment procedure and post-treatment care was explained to me in detail and I understand it and agree with it. *YesSend me a copy.PreviousSubmit
