CONSENT FORM - rose-and-remed

Client Name

DOB:

Phone

BENEFITS Improved tone/texture, reduced fine lines & scars, smaller pores, better product absorption
POSSIBLE RISKS Redness, swelling, dryness, flaking or pinpoint bleeding (microneedling), allergic reaction to products, infection (rare), hyper/hypopigmentation

Check any that apply:

Have you used any in the last 7 days?

Allergies to skincare, metals, or numbing agents?

Yes No

NANO-NEEDLING is gentler and non-invasive. It treats surface concerns like dullness & fine lines with little to no downtime & improves product absorption without breaking the skin barrier.

I understand and consent to microneedling and/or nano-needling based on the provider’s recommendation.

AFTERCARE INSTRUCTIONS
Expect mild redness or tightness for 24–72 hours. Avoid makeup, exercise, sweating, or sun exposure for 24- 48 hours. Use only gentle cleansers and hydrating serums for 3–5 days. No retinoids, exfoliants, or acids for at least 5 days. Apply SPF daily. Do not pick or exfoliate peeling skin.
CANCELLATION POLICY
We understand that things happen. If you need to cancel, please do so at least 48 hours in advance. If you need to cancel in less than 48 hours, you will be charged half of the total cost of your service. Same day cancellations and no- shows will be charged at full price.
CONSENT & RELEASE By signing below, I confirm:
I’ve disclosed all relevant health info, medications, and allergies. I understand the procedure, risks, and benefits. I agree to follow all pre/post care instructions. I release the provider from liability related to omitted health info or adverse reactions.

Client Signature:

Practitioner Signature:

ROSE & REMEDY

ROSE & REMEDY

📋 Consent Form Required

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