HEALTH FORM & WAIVER
Please fill out the following form to help us understand your physical condition.
Skin Needling/Scar Revision/Camouflage
Medical and Consent Form
I am aware of the fact that in the event of pregnancy, I will be advised against undergoing a skin needling treatment due to increased susceptibility to infections iF iF I DO suffer from any form of the following: • Hemophilia • Chronic skin disease • Contact allergy • Diabetes • Immune disorder • Cardiovascular disorders If I have answered ‘Yes’ to any of the above, I UNDERSTAND that any form of skin needling is not recommended and that NUDETATU has clearly explained the implications of these disorders on the treatment to which I consent.
I wish to begin a series of skin needling treatments on the Face/and or Body. I understand that the fine needles used during the skin needling treatment, induce the production of the body’s own new collagen. The needles penetrate the epidermis (top layer of the skin) and cause micro-injuries. Due to the wound healing process, a lot of different healing factors are released into the skin. This leads to the formation of collagen and elastin fibers under the skin surface. I understand that skin needling can have the following side effects: Redness and swelling: During the first days after treatment, redness and swelling can occur. This is because the needle penetration does force micro lesions, which disappear during the healing process. The wounds will close very quickly and about 24 hours after treatment an appropriate makeup can be used. Keloid: If you have the tendency to form keloid scars, the micro lesions, which are caused during the skin needling, can also lead to keloids. Hyperpigmentation: It is very rare but possible that hyperpigmentation occurs in the treated area. E.g. after excessive sun exposure. A sun protector of 30+ can prevent this. Herpes simplex: If you have suffered from herpes simplex, the skin needling treatment can force it again. A premedication can prevent this. Furthermore bruising, inflammation, itching and moderate pain can occur after the treatment. I understand that it is important to keep out of the sun after the treatment to avoid hyperpigmentation. If I stay outdoors during sunny weather I MUST use sun protection with at least SPF 30
I understand that skin needling is performed in a series of treatments. Depending on the age of skin and the desired result there will be usually a minimum of 3-6 treatments needed in approximately 2-6 week intervals. The treatment and possible side effects have been explained to me and I had the opportunity to get all my questions answered to my full satisfaction. I understand that the purpose of the treatment is to improve the appearance of the skin. It is possible that the intended improvement will not lead to my expected result and that my expectations will not be reached.
I confirm that my personal data as well as the answers to my medical history are correct and to the best of my knowledge. My clinical history has been discussed and possible contraindications have been precluded.
During the last 5 MONTHS prior to the treatment, I have not gone through dermabrasion, surgery, or radiation therapy in the treatment area that is requiring INK (SKIN TONE PIGMENT). ** This does not apply to Inkless treatments only camouflage requiring ink!
I understand that it is not only important to follow all instructions, but to also show up for all visits as described above to get optimal treatment results.I confirm that I will follow the pre and post-care instructions and I have received post procedure instructions and healing information and I will adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. I confirm that all my questions have been discussed and that I have been given information about effect, treatment method and possible side effects. I hereby authorize Nude Tatu to take photographs of the work performed both before and after and use of said photographs to be used to show potential clients as an example of work performed by Nude Tatu for the purpose of advertising. I also authorize Nude Tatu to take photographs of the work performed both before and after treatment to be kept in file.
I am fully aware that all of my procedures will be performed by Nude Tatu and it’s practitioners. I hereby agree to waive and release to the fullest extent permitted by law Nude Tatu and it’s practitioners from ALL liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors, or assigned may have for personal injury or otherwise, including and direct/and or consequential damages which result or arise from the application of my Permanent Cosmetic tattoo, whether caused by negligance or fault of NUDE TATU or it’s practitioners.
I agree to reimburse Nude Tatu and its practitioners for any attorneys’ fees and costs incurred in any legal action I bring against Nude Tatu or its practitioners in which Nude Tatu or it practitioners is the prevailing party. I have reviewed and understand all the information given to me. I understand this is a contract and that I have received no warranties or guarantees with any of my procedures.). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself. • I have made an informed decision to undergo skin needling and do so of my own free will. • I was not under the influence of alcohol or drugs before or during the treatment. • I do not currently have any swelling, bumps, or other forms of irritation on my body and consider myself healthy enough to undergo this cosmetic treatment. • I am not currently using any anticoagulants. • In the event a dermatologist is treating me, I consulted the dermatologist before deciding whether or not to undergo a skin needling treatment.