Consent Form for Micro Sclerotherapy

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.

First Name^*

Last Name^*

Client Ref

Treatment Date

Treatment Name

Patch Test Date

Personal Information

Date of Birth^*

Address

Street Address^*

Street Address (line 2)

City^*

State / Province^*

Postal / Zip Code^*

Country^*

Phone Number

Area Code^*

Phone Number^*

E-mail^*

How did you hear about us?

Website / Online Search

Instagram

Facebook

Referral

Other

Expectation of treatment outcome

Contact Person

First Name

Last Name

Street Address

Street Address (line 2)

City

State / Province

Postal / Zip Code

Phone Number

Area Code

Phone Number

Relation

AFTERCARE ADVICE FOR AESTHETIC PRCEDURES

Micro Sclerotherapy

Anyone undergoing sclerotherapy should adhere to the following recovery guidelines:

DO wear compression stockings or tight leggings until bedtime for 14-21 days (or other timelines developed by your provider) after treatment. It is not necessary to wear compression stockings/tight leggings while sleeping or bathing.
DO NOT experience excessive sun exposure to treated areas for at least one month after treatment. This can cause hyperpigmentation.
DO postpone any strenuous activities or high-impact workouts for one week after treatment.
DO NOT take any hot baths, showers, or sit in hot tubs for one week after treatment.
DO NOT be overly sedentary during your recovery. An important part of your recovery is walking.
DO take ibuprofen, Advil, or other anti-inflammatory medications as directed by your provider.

I grant permission to MB Derma Clinic to use my photos and all forms of media for marketing, promotional literature, educational and social media purposes. I will not require any payment for that. ^*

Preparing for your appointment

DAY OF PROCEDURE and at least 12 hours prior to NO sweating (no working out); NO caffeine (coffee, energy drinks, etc.) NO alcohol. DO NOT have sunburned skin on the face.

Please shower and tidy your hair as you may not be able to shower 3 days after treatment due to the nature of the procedure

ONE WEEK BEFORE PROCEDURE (5 days): discontinue all blood thinners such as aspirin, vitamin E, ibuprofen, naproxen, niacin, fish oil, herbal supplements (physician clearance is required if blood thinners are medically necessary). NO waxing or threading. Take antiviral medication if you are prone to cold sores/ fever blisters/ HSV to prevent post-treatment outbreak.

TWO WEEKS BEFORE PROCEDURE (14 days): NO eyebrow tinting, tanning bed, sunbathing. NO enzymatic, lactic or chemical peels. NO glycolic or salicylic acids in skincare. NO exfoliating treatments (microblading, dermaplaning, etc.).

THIRTY DAYS BEFORE PROCEDURE (30 days): NO Botox, Dermal Fillers, AHA products, Retinols, and laser skin resurfacing treatments. Discontinue brow and lash growth serum.

ONE YEAR BEFORE PROCEDURE: discontinue Accutane
Allow up to 3 hours for your appointment.

It's recommended your 2nd session is within 30-60 days.

Please note that you will be more sensitive during your menstrual cycle.

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the MB Derma Clinic skin care professional of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release MB Derma Clinic and/or the skin care professional from liability and assume full responsibility. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.^*

I have received After Care Instructions as a separate document and agree to follow them^*

To cancel an appointment, please do so at least 48 hours prior to your appointment. ^*

I have read and fully understand the contents of each paragraph and page of this contract. I acknowledge this is a legal & binding contract and that I have received no warranties or guarantees with respect to the benefits to be realized from or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself.

Date

Signature^*

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Consent Form for Micro Sclerotherapy

Personal Information

Address

Phone Number

Contact Person

Phone Number

Health Questionnaire

Medical History

Skin Type

AFTERCARE ADVICE FOR AESTHETIC PRCEDURES

Micro Sclerotherapy

Preparing for your appointment

Upload your photo

Upload some desired results