Facial Sculpting

Micro Needling Consent Form

Patient Name:  

Date of Birth:  

Micro-Needling Informed Consent

AQ Skin Solution or SKinrolla 0.5-1.5 mm device improves the health and quality of the skin by stimulating essential cells to increase collagen, elastin and hyaluronic acid. It is an effective treatment for acne scarring, stretch marks, fine lines and wrinkles, open pores, and generally improves skin tone, texture and brightness. Results are gained gradually over a period of months.

Common Side Effects

  • Redness which ranges from a pale rose blush to a beetroot red. This redness usually settles within a few hours but can persist for up to 3 days settling daily.

  • Swelling

  • Mild discomfort/ heat, tingling, not unlike sunburn

  • The skin may feel dry over the first 7 days and will require the application of aftercare cream for comfort

  • Light peeling/flaking may occur, particularly after the first treatment.

  • Sensitivity to your usual skin care regime.

  • Red marks/ ‘track marks’

Rare Side Effects

  • Bruising, small dark purple bruises

  • Infection

  • Prolonged redness

  • Herpes/ cold sore outbreak

  • Pigmentation changes – hyper-pigmentation (darkening of the skin treated) or loss of pigment

  • Severe itching, selling and redness (temporary)

  • Scarring

Whilst I have been advised of the probable result, this cannot be interpreted as a guarantee. Results Vary from one individual to another.

Permissions Requested;

I consent to photographs being published for;

I have taken the time to read;

and accept the terms of payment as per the clinic policy (terms and conditions).


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Signed by Nina Bal
Signed On: 8th January 2020

Signature Certificate
Document name: Micro Needling Consent Form
lock iconUnique Document ID: dc2dc879efee91c78f43f03e9ab7b821d4812042
Timestamp Audit
7th November 2019 4:08 pm BSTMicro Needling Consent Form Uploaded by Nina Bal - info@facialsculpting.co.uk IP