Microchanneling Screening Form

Step 1 of 4

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Name(Required)

Date(Required)

MM slash DD slash YYYY

Address

Street Address City State ZIP

Home Phone(Required)

Cell Phone(Required)

Email(Required)

Referred by

Are you over 18 years of age?(Required)

Yes

Do you take aspirin or blood thinners regularly?(Required)

Yes

Have you had injectables in the past 30 days?(Required)

Yes

Have you taken any mood altering drugs in the past 8 hours?(Required)

Yes

Do you have a history of cold sores, herpes or fever blisters?(Required)

Yes

Are you sensitive to Latex?(Required)

Yes

Have you had a chemical or LASER peel? If so, when?(Required)

Yes

when?

Do you have trouble healing?(Required)

Yes

Are you currently undergoing radiation or chemotherapy?(Required)

Yes

Are you currently using Retin-A, AHA, or other exfoliating skin care products?(Required)

Yes

Are you allergic to any metals?(Required)

Yes

Are you currently taking anti-inflammatory medications or steroids?(Required)

Yes

Are you allergic to any anesthetics, (any of the “caines”)?(Required)

Yes

Do you have a history of skin disease?(Required)

Yes

Do you have a history of skin sensitivity?(Required)

Yes

Are you currently taking vitamin A or E in any form?(Required)

Yes

Are you pregnant or nursing?(Required)

Yes

Are you currently being treated by a dermatologist?

Yes

Specific for Scalp Treatments

Have you had Hair Transplants? If so, when?(Required)

Yes

Do you have Psoriasis of the Scalp? If so, when?(Required)

Yes

Have you had Micropigmentation of the Scalp? If so, when?(Required)

Yes

Have you had any chemical services on the Scalp within the last 48 hours?(Required)

Yes

Please circle(check) any that apply to you:

Heart Condition

Hepatitis

HIV

Cold Sores

Hyper Pigment

Smoker

Keloid Above Neck

Accutane in last 2 yrs

Allergic to Steel

Diabetes (uncontrolled)

Chronic Skin Disease

Hemophilia

Practitioner’s Name

Practitioner’s Signature

Microchanneling Consent Form

Patient Name

Date

MM slash DD slash YYYY

I authorize

to perform Microchanneling on my skin, and to apply topical preparations as determined necessary.

I understand that Microchanneling is non-ablative skin rejuvenation / hair rejuvenation and involves the creation of perforations in my skin to promote healing responses to rejuvenate my skin / hair. 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 reddening, peeling, scabbing, temporary bruising and temporary discoloration of the skin / scalp as well as rare side effects such as infection & scarring.

These effects have been fully explained to me.

Clinical results may vary depending on individual factors, including medical history, amount of sun damage or textural problems, skin type, type of hair loss and my compliance with pre/post treatment instructions.

I understand that the Microchanneling treatment may involve a series of treatments and the fee structure has been fully explained to me.

I understand there will be NO refunds for any services I receive.

I understand Red light therapy will enhance and accelerate the procedure.

I consent to the use of Red light therapy.

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. 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 have been made aware of the referral program my practitioner offers.

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.

Signature

Date

MM slash DD slash YYYY

Microchanneling Treatment Chart

Patient Name

Date

MM slash DD slash YYYY

Areas

Needle Depths

# Passes

Please enter a number less than or equal to 10.

Recommendations for Future Treatment:

Post care information given

Notes:

Practitioner Sign Off:

Signed:

Date

MM slash DD slash YYYY

Signed:

Date

MM slash DD slash YYYY

Signed:

Date

MM slash DD slash YYYY

Referrals:

Microchanneling Post-Care

If any Microchannel Delivery Solution roll-on remains, apply continually until gone. This is for skin and scalp treatments.
No other products should be applied until the following day.
Scalp treatment nothing on the scalp for 90 min. e.g., Hats or Wigsv
When the numbing wears off your skin may feel like a mild sunburn. You may apply cool compresses as desired. Scalp treatments no numbing is used.
Needle lengths of 0.25mm, 0.5mm will result in mild redness and swelling for up to 24 hours.
Needle lengths of 1mm, to 1.5mm will result in redness and swelling for up to 72 hours.
Beginning the following morning; apply the Livra Cellular Renewal Serum and Healing Accelerator to enhance results. This is available for purchase the day of your treatment. (Cleanse and apply 1-3 pumps). Apply daily, morning and evening.
Scalp treatments use Nioxin System and Supplement this is available to purchase the day of your treatment.
Peeling and skin sloughing may occur for several days after treatment.v
Scalp treatment air dry your hair DO NOT dry hair aggressively with a towel after washing.
Trans Epidermal Water Loss is a common temporary side effect and could leave you feeling dry.
Return for a follow up treatment 4 weeks for skin, 2 weeks for scalp or as recommended.

If prolonged irritation occurs, please call

Practitioner Name

Practitioner Phone #

Microchanneling Screening Form

Specific for Scalp Treatments

Microchanneling Consent Form

Microchanneling Treatment Chart

Practitioner Sign Off:

Referrals:

Microchanneling Post-Care

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