Microchanneling Consent Form

Records a client's skin history and informed agreement before a microchanneling session. Made for spas, clinics and skincare professionals who need a signed acknowledgement on file.

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Full name

First Name

Last Name

Phone number

Date of birth

Have you had microchanneling or a similar treatment before?

Yes No

Do you have any known allergies or sensitivities?

Do you have any skin conditions (e.g., eczema, psoriasis)?

Are you taking any medications? If so, please specify.

Are you pregnant or breastfeeding?

Yes No

I understand that microchanneling is a cosmetic procedure that creates tiny micro-injuries in the skin to stimulate renewal.

I agree I do not agree

I acknowledge that results differ from person to person and no specific outcome is guaranteed.

I agree I do not agree

I have been able to ask questions about the procedure and received satisfactory answers.

I agree I do not agree

I consent to the treatment and agree to follow my practitioner's pre- and post-treatment instructions.

I agree I do not agree

Signature

Sign here

Date

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