RF MICRONEEDLING CONSENT FORM

PATIENT INFORMATION:

First Name

Last Name

Date Of Birth

Phone/Mobile

City

Next Of Kin

Kins Contact Number (Phone/Mobile)

MEDICAL HISTORY

Do you have a history of skin disorders or infections?

Yes

Do you have a history of keloid scarring?

Yes

Pregnant or breastfeeding?

Yes

Do you have any other medical conditions?

Yes

Your other conditions

Procedure Description:

I understand that I am receiving a RadioFrequency Microneedling treatment. An RF Microneedling is a minimally invasive procedure that uses tiny needles and radiofrequency waves to rejuvenate facial skin. The treatment is a form of controlled skin injury. The damage stimulates the growth of healthy new skin which is used to treat skin concerns, reduce the appearance of acne scars and stretch marks, fine lines, loose skin, and wrinkles.

Benefits and Risks:

I have been informed that the benefits of an RF Microneedling may include:

• Smoother and more youthful-looking skin

• Reduction in the appearance of scars, acne, fine lines, wrinkles, and stretch marks

• Improved skin texture and tone

I understand that there are potential risks and side effects associated with RF Microneedling, including:

• Temporary redness, swelling, or bruising on the treated area

• Short-term irritation or skin sensitivity

• Allergic reaction to topical products used during the procedure

• Mild discomfort during the procedure

• Infection or scarring (rare but possible)

Aftercare:

I agree to follow the post-treatment instructions provided by the clinician to ensure the best possible results and minimize any risks. I understand that failure to adhere to these instructions may increase the likelihood of complications.

Consent for Treatment:

I hereby consent to undergo a Radiofrequency Microneedling treatment. I acknowledge that the clinician has explained the procedure, its benefits, and potential risks to me. I have had the opportunity to ask questions, and all of my concerns have been addressed to my satisfaction. I understand that the results of an RF Microneedling can vary, and multiple sessions may be required for optimal results.

Release of Liability:

I release The Abram, its employees, and representatives from any liability associated with the RF Microneedling treatment, except for cases of negligence or intentional misconduct.

Pictures or Videos will be obtained for medical records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed

Initial

I agree that all the above information is true and accurate to the best of my knowledge

Client’s signature: