Facial Forms | MK WELLNESS

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First name

Last name

Phone

I agree to be contacted by phone and email.

Other conditions not listed above:

Current medications (including aspirin, ibuprofen, vitamins, herbs, homeopathic and naturopathic remedies):

How much water do you drink per day?

Leisure Activities:

Alcohol Consumption:

Eating Habits:

Are you a smoker? How much per day?

Work Habits (hours/day)

Emotions and mental health at the moment?

Sleeping Habits:

What is your current skincare routine?

What is your goals for today's treatment?

Consent for Skin Needling/ Facial Treatment

I understand that there may be some degree of discomfort including inflamation,bruising and redness with having this treatment.

I understand that my skin will be pricked repeatedly so it will lose some blood. (This stops withing minutes and then a straw colour fluid may ooze from the tiny holes. This also stops withing a few minutes.)

I understand there are no guarantees to the results of this treatment due to many variables such as age and condition of the skin.

I understand that for the first 24 hours after treatment I must only apply the products recommended and not apply any makeup or sunscreen. (This is due to the micro channels remaining open for 24 hours after)

I understand that this is a cosmetic treatment and no medical claims have been implied.

I understand to achieve maximum results, I may need several treatments.

I understand that although complications are very rare, sometimes an unexpected outcome may occur and that prompt treatment would then be necessary. If anything occurs I will immediately contact the therapist who performed the treatment.

I consent to the dry needling treatment and agree to follow my post-care treatment advice and to use only the skin care products as recommended by the therapist who conducted the procedure.

I acknowledge that whilst certain benefits are likely to result from this treatment as discussed with me, individual results will vary and that no guarantee of a likely outcome can or has been given.

I agree to for the therapist to use Heidi Help - a note transcribing AI.

I agree to the terms & conditions and give consent for my treatment.

I understand the potiential risks and adverse reactions of the facial treatment.

Signature

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