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NOW OFFERING PROCELL MICROCHANNALING!
HAIR REGROWTH CONSENT FORM
First Name
Last Name
Phone
Select a date
Street Address
City
Region/State/Province
Postal / Zip code
Country
Email
Referred by:
Are you over 18 years of age?
*
Yes
No
Do you take aspirin or blood thinners regularly?
*
Yes
No
When did your hair start thinning?
Have you taken any mood altering drugs in the past 8 hours?
*
Yes
No
Do you have a history of cold sores, herpes or fever blisters?
*
Yes
No
Are you sensitive to Latex?
*
Yes
No
Have you had other hair regrowth treatments?
Do you have trouble healing?
*
Yes
No
Are you currently undergoing radiation or chemotherapy?
*
Yes
No
Are you allergic to any metals?
*
Yes
No
Are you currently taking anti-inflammatory medications or steroids?
*
Yes
No
Are you allergic to any anesthetics, (any of the “caines”)?
*
Yes
No
Do you have a history of skin disease?
*
Yes
No
Do you have a history of skin sensitivity?
*
Yes
No
Are you currently taking vitamin A or E in any form?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
Have you ever been diagnosed with “Male Pattern Baldness”?
*
Yes
No
Please circle any that apply to you:
Heart Condition
Hyper Pigment
Allergic to Steel
Hepatitis
Smoker
Diabetes (uncontrolled)
HIV
Compromised Immunity
Chronic Skin Disease
Cold Sores
Accutane in last 2 yrs
Hemophilia
Practitioner’s Name
I authorize Skin Supreme to perform Microchanneling on my scalp, and to apply topical preparations as determined necessary.
I understand that Procell Microchanneling for hair regrowth is involves the creation of perforations in my scalp to promote delivery of product to reactivate follicles affected by Alopecia. I understand that the procedure is performed with an automatic perforating device and that clinical results may vary. I understand there is a possibility of short-term effects such as pain, reddening, peeling, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as infection & scarring. These effects have been fully explained to me.
I understand clinical results may vary depending on individual factors, including medical history, amount of, and longevity of hair loss, and my compliance with pre/post treatment instructions.
I understand that the Microchanneling treatment may involve a series of treatments and that the fee structure has been fully explained to me.
I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained, and that there are no refunds offered for lack of satisfactory results. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.
I confirm that I am not pregnant at this time. I also have completed a medical history checklist and been informed about what I must do and “not do” before, during and after the procedure.
I consent to the taking of photographs and authorize their anonymous use for the purposes of clinical audit, education and promotion.
I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.
I furthermore indemnify the authorized person herein, and hold harmless from any and all claims, demands, liabilities, judgments, costs and expenses arising out of any claims relating to the procedure authorized herein.
Your Signature
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SUBMIT
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