Download attached consent - Cheshire Lasers

Please bring this form along to your appointment. Please do NOT sign any consent prior to your
consultation.
MODEL PREPARATION & CONSENT FOR CIT NEEDLING TREATMENTS
Full Name
DOB
Contact Tel:
Email:
PATIENTS WHO SHOULD NOT BE TREATED:
 Active cold sores or warts, you must inform the practitioner in advance of treatment if
you have any history of herpes simplex.
 Open wounds, or recent scars.
 Skin conditions such as psoriasis, eczema, dermatitis, lichen planus, inflammatory
rosacea in area to be treated, severe acne, frequent rashes or any other skin conditions,
infection or reactions.
 Sunburn, or recent moderate to heavy tanning
 Excessively sensitive skin
 History of allergies
 Known sensitivities to any of the components of this treatment (Including metals)
 If you have taken Roaccutane or any Corticosteroids within the past year
 Treated with chemotherapy or radiation therapy.
 Keloid Scarring
 Auto immune disorders
 Pregnancy or Breast Feeding
 Current illness
 Injectable treatments such as Botulism or Hyaluronic Acid based semi permanent fillers
if carried out within the 6 weeks before treatment
 Those with permanent fillers should not be treated in the area where present.

PLEASE CONFIRM THAT YOU HAVE NONE OF THE FOLLOWING BEFORE AGREEING TO PROCEED
WITH TREATMENT
Pregnancy Yes No
Use of Roaccutane Yes No
Cold sores (Herpes outbreak) Yes No
Acne Yes No
Plastic surgery in last 6 months Yes No
Use of Retin A/Retinova/Retinol products Yes No
Please list any current medications below: Please bring this form along to your appointment.
Please do NOT sign any consent prior to your consultation.
Please confirm that you have discussed any medical
conditions and medications with your practitioner.
Further Considerations for Consent
Although CIT needling is highly effective in most cases,
no guarantee can be made that a specific patient will benefit or how much they will benefit
for a specific condition.
1) I acknowledge that no guarantee has been given to me as the condition of the complexion, ie
skin pore size, wrinkle reduction.. or the amount or percentage of improvement to be expected
for me individually following treatment.
2) I acknowledge that for many conditions, more than one treatment may be required to
achieve the desired result. In fact, a course of 3 is recommended for optimum results.
3) I acknowledge that no guarantee or assurance has been made by anyone regarding the
procedure that I herein request and authorize.
Consent
By signing below, I acknowledge that I have read the informed consent regarding treatment and
I feel I have been adequately informed regarding the associated risks. I hereby give consent for
the procedure to be performed and I have disclosed any condition that may be contraindicated
for treatment.
Patient Signature ___________________________________________________________
Date
Practitioners Signature ________________________________________________________
Date
Please bring this form along to your appointment. Please do NOT sign any consent prior to your
consultation.
TWO-WEEKS BEFORE YOUR TREATMENT
Avoid these treatments for 2 weeks prior to your
Dermaroller treatment:
• Electrolysis
• Waxing
• Depilatory Creams
• Laser Hair Removal
ONE-WEEK BEFORE YOUR TREATMENT
Stop using:
• AHA or BHA, or benzyl peroxide
• Any exfoliating products that may be drying or irritating
24 HOURS BEFORE TREATMENT
Avoid alchohol
DAY OF TREATMENT
Cleanse your skin and moisturise in the morning as usual, do not apply heavy makeup on face
other than eyes and lips.
AFTER YOUR CIT NEEDLING TREATMENT – it is imperative that you follow advice to ensure
health of your skin and increase the success of your treatment
Guidelines be followed:
1. Do not use any AHA’s or BHA on your skin for 24hours
2. Only apply products recommended and for the timescale recommended by your practitioner.
3. It is imperative that you use a sunscreen with an SPF of at least 30 and avoid direct sunlight ie
sunbathing for at 1 month. Patients with hypersensitivity to the sun should take extra
precautions to guard against exposure.
4. Your skin may be more red than usual for 2 hours.
5. Please avoid strenuous exercise until all redness and inflammation has dissipate, it is advised
that you avoid for at least 48 hrs.
6. You may have some peeling or flaky skin for a few days DO NOT PICK OR PULL THE SKIN!
8. When washing your face, do not scrub. Use a gentle cleanser designed for Sensitive skins
9. Apply a light moisturiser as often as needed to relieve dryness and tightness.
10. Do not have any other facial treatment for at least one week after your Dermaroller
treatment