Reemake Skin Medical Spa + Laser Clinic

MicroChanneling Screening Form

Name:
Date:
Are you over 18 years of age? YesNo
Have you taken aspirin or blood thinness in the past 7 days? YesNo
Do you have an allergy to Aloe Vera? YesNo
Have you taken any mood altering drugs in the past 8 hours? YesNo

(initial) I understand that if I have a history of cold sores, herpes or fever blisters I must take my medication prescribed by my physician in advance or tell the technician to skip treatment around my lips.

Are you sensifive to Latex? YesNo
Have you had a chemical or LASER peel? YesNo
Do you have trouble healing? YesNo
Have you had any botox or fillers? YesNo
Are you currently undergoing radiation or chemotherapy? YesNo
Are you currently using Accutane, Retin-A, AHA, or other exfoliating skin care products? YesNo
Are you allergic to any metals? YesNo
Are you currently taking anti-inflammatory medications or steroids? YesNo
Are you allergic to any anesthetics, (any of the “caines”)? YesNo
Do you have a history of skin disease? YesNo
Do you have a history of skin sensitivity? YesNo
Are you currently taking vitamin A or E in any form? YesNo
Are you pregnant or nursing? YesNo
Are you currently being treated by a dermatologist? YesNo
Derm name:

Please circle any that apply to you:
Heart ConditionHepatitisHIVCold SoresHyper PigmentSmokerKeloid Above NeckAllergic to SteelAccutane in Iast2 yrsDiabetes (uncontrolled)Chronic Skin DiseaseHemophilia

1. If you get cold sores regularly, taking acyclovir or valcyclovir starting one day prior to your mlcrocharinelin will reduce the likelihood of a breakout due to your treatment.

2. Discontinue retinol (2°4 or higher) or tretinoin at least 3 days prior to treatment.
3. For your first treatment (and treatments at 0.25mm in general), the numbing cream is not typically necessary. You can expect mild redness, swelling and a tight, warm sensation from 4 to 24 hours post-treatment.

4. Later treatments with longer mic«-filament lengths may require topical numbing cream, and can produce redness and swelling along with tiny flecks of redness for between 4 & 72 hours.

5. If your liver, kidneys and immune system are healthy, taking an NSAID such as lbuprofen 2 hours before treatment can reduce discomfort.

6. If you are being treated for hair loss, please arrive at the office with the shortest haircut possible and clean hair. Please do not apply sprays or gels.

7. If you are being treated with PRP or PRF drink an extra 24-32 oz of water for two to three bays prior to treatment.

8. If possible, please arrive at the Studio with a clean, make-up free face. For men, a clean, dean shaven face.

9. If you’ve had Botox, Fillers or Threads injected you must wait at least two weeks before treatment. You must be satisfied with the results before we can offer you any other treatments.

I have read the above information, and I give my consent to have the Microchanneling treatment by the staff at Reemake Studio.

Signature:
Date:
Notes:
1. If you are pregnant or nursing, you are advised to not receive any MicroChanneling treatments. To date, there have been no studies conducted to see what effects these treatments may have on the unborn child. However, as a general rule, pregnant women should stay away from any type of cosmetic/elective procedures.
2. Unstable diabetes patients should not be treated due to healing problems
3. If you have active Herpes Simplex in the treatment area, the treatment is only possible once the outbreak has healed. However, it may be advisable to take prescription strength antiviral medication to keep this condition in remission during the treatment series.
4. If your skin is overly dry, you will need to start moisturizing more to ensure the condition is under control prior to undergoing any treatment.
5. Any active inflammatory skin condition, for example: eczema, psoriasis, infection, rash or any type of dermatitis, at the treatment site as it may aggravate the condition.