Lavender Falls Face & Body Spa LLC

Client Informed Consent Form





19239 Stone Oak Pkwy, Suite #201

San Antonio, Texas 78258

Phone: 210-446-0903


Online Booking Available

Treatment Consists of:

Micro-needling treatment allows for controlled induction of the skin’s self-repair mechanism by creating micro-”injuries” in the skin, which triggers new collagen synthesis, yet does not pose the risk of permanent scarring. Micro-needling has been shown to reduce the visibility of acne scars, fine lines and wrinkles, diminish hyperpigmentation, and improve skin tone and texture, resulting in smoother, firmer, younger looking skin.

Client Acknowledgements:

Absolute contraindications include: scleroderma, collagen vascular diseases or cardiac abnormalities; rosacea or blood clotting problems; a hemorrhagic disorder or haemostatic dysfunction; active bacterial or fungal infections; immuno-suppression; scars less than 6 months old; and facial fillers used in the past 2 - 4 weeks.

Contraindications and precautions include: keloid or raised scarring; history of eczema, psoriasis, actinic (solar) keratosis, herpes simplex infections, diabetes, and other chronic conditions; presence of raised moles, warts or any raised lesions in the target area. Treatment is not recommended for patients who are pregnant or nursing

Information: I acknowledge I am not currently nor have used any of the products listed below within the time frame listed.

Pre-Treatment Acknowledgement

     ·  Accutane with the last year

      ·         Allergies -I am not allergic to any of the ingredients in the prescribed treatment.

      ·         Sunburn or Sun Exposure- 1 week prior to treatment.

      ·         Recent Laser Treatments or Chemical Peels

      ·         Electrolysis, Waxing , Depilatory Creams , Laser Hair Removal – 1 week prior to treatment

      ·         No prescriptive topicals, abrasive scrubs or strong exfoliants – 1 week prior to and post treatment.

(Retin-A, Renova, Differin (Adapalene 0.1%), Tazorac or any product containing Retinol, glycolic acid, salicylic acid)

      ·         Pregnant or Breastfeeding


Cosmetic Injections:

      ·         Botox/Dysport/Xeomin within the last week.

      ·        Dermal Fillers within the last 2-4 weeks.

*Notify your aesthetician of any medical conditions & medications (Current & within the last 90 days).

Post Treatment Acknowledgement

      ·         The skin will be red with mild swelling and/or bruising, and your skin might feel tight and sensitive to the touch. Although these symptoms may take 2-3 days to resolve completely, they will diminish significantly within a few hours after treatment.

      ·        You MUST avoid sun exposure for 1- 2 weeks post treatment.

      ·         Sun protection of at least broad spectrum SPF 30 is recommended.

      ·         Avoid picking and/or peeling the skin during healing period.

      ·        Do not take any anti-inflammatory medications such as ibuprofen, Motrin or Advil. These agents will interfere with the natural inflammatory process that is critical and responsible for your skin rejuvenation.

      ·         Treat skin gently over the next 24 to 48 hours allowing the natural healing process to take effect.

      ·        You may clean your face with a gentle cleanser before bed.

      ·         Restart regular skin care regimen in 48 hours and Retin A in 72 hours.

Side Effects/Risks

Possible side effects include but are not limited to:

• Common side effects such as redness and mild swelling usually subside within a few hours after treatment. Bruising, skin irritation (Itching, burning, redness) and exacerbation of skin breakout can occur and may take 2-3 days to resolve.

• Infection- Infection is very unusual. However, viral, bacterial, and fungal infections can occur.

A sudden reappearance of redness or pain is a sign of infection and you should notify our office immediately.

• Hyperpigmentation- is very rare; however, failure to follow post treatment instructions can put you at risk for hyperpigmentation.

• Scarring - abnormal scars may occur in both the skin and deeper tissues. In rare cases, thickened or keloid scars may result, especially if you are prone to keloid scarring.


      ·         I understand that any time the skin barrier is compromised; there is a small risk of infection. I will contact my aesthetician immediately should this happen.

      ·         The Micro-needing treatment has been fully explained and any questions or concerns that I have, have been addressed.

      ·         I acknowledge that no guarantee has been given to me as to the condition of the complexion, skin pore size, wrinkles or the percentage of improvement expected following treatment, due to each individual’s unique reactions.

      ·         I acknowledge this procedure is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied.

      ·         Photographs May be taken for comparison for future treatments for my chart.


I have read the above and understand it. My provider has answered my questions satisfactorily. I accept the possible risks and complications of the treatment.


I acknowledge that Lavender Falls Face and Body Spa has a no-refund policy on any products or service. There will be no refunds for any reason.


All services performed are without any guarantee. By continuing with service, you are confirming that you have read and understand our no refunds policy.







Lavender Falls Face and Body Spa LLC

Thank you for choosing and trusting Lavender Falls Face & Body Spa LLC for your aesthetic needs

Feel free to contact us at 210-446-0903 if you have any questions



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Signature Certificate
Document name: Micro-Needling
lock iconUnique Document ID: 2715602a27b067dc1d3986868bca5a951c6cbdf6
Timestamp Audit
April 17, 2017 3:42 pm CSTMicro-Needling Uploaded by Lavender Falls Face and Body Spa LLC. - lavenderfallstx@gmail.com IP