Name *

First Name

Last Name

DOB *

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Phone *

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Patient Consent *

I acknowledge that individual results may differ and recognize that while I might observe changes after my initial treatment, a series of sessions will likely be necessary to achieve my desired results.

The procedure, potential side effects, and alternative options have been thoroughly explained to me, along with their respective benefits and drawbacks.

I understand that although favorable outcomes are anticipated, the likelihood and specifics of complications cannot be precisely predicted, and thus, no guarantees regarding the treatment's success or results can be made, either explicitly or implicitly.

I am aware that the effects of microneedling are not permanent, as natural degradation will occur over time.

I confirm that I have read this consent form (or it has been read to me) and comprehend the information it contains.

I have had the chance to inquire about the treatment, including its risks and alternatives, and I acknowledge that all my questions have been satisfactorily addressed.

Digital Signature *

First Name

Last Name

Date *

MM

DD

YYYY