U&I Spa Inc

BB GLOW & MICRONEEDLING

130 West 57th Street, Suite 14A
New York, NY, 10019

Phone: 917.214.9910
Email: uandispa@gmail.com

Please answer all questions below and press the [SUBMIT] button on all forms.

1. PERSONAL INFORMATION

*Name

*AddressStreet Name, #, City, State, ZIP

*Birthdate

*Phone Number

*Emergency Contact Phone Number

*Relationship

*Email

How did you hear about us?

2. GENERAL INFORMATION ABOUT PROCEDURE

What is BB Glow Treatment?

BB Glow treatment is an anti-aging and skin brightening procedure based on MTS Microneedle Therapy System, which is based on the skin´s natural ability to repair itself when it suffers physical damage. Immediately after an injury to the skin, the body begins a healing process, triggering new collagen synthesis.

How is BB Glow Done?

The procedure is safely done using a Microneedling Pen with a single-use sterile needle head. The device offers adjustable depth, speed, and needle size control. A session usually takes 2 hours, in which serums and/or pigments will be applied to stimulate the rejuvenation process along with a facial hydrating mask at the end.

What to Expect after a BB Glow Treatment?

Skin will be red with a mild swelling and/or bruising, skin might feel tight and sensitive to the touch. Although these symptoms may take 1 to 2 days to resolve completely, they will diminish significantly within a few hours after the treatment.

3. HEALTH

*Do you have any of the following?

*Kelloid/Hypertrophic Disease

Yes

*Active Infection (viral, bacterial, fungal)

Yes

*Blood Thinner Medications

Yes

*Recent Chemical Peel

Yes

*Active Acne

Yes

*Hormone Replacement

Yes

*Chemotherapy or Radiation

Yes

*Scleroderma

Yes

*Sunburn

Yes

*Uncontrolled Diabetes

Yes

*Collagen Vascular Disease

Yes

*Eczema, Psoriasis, Dermatitis

Yes

*Raised Lesions or Moles

Yes

*Hemophilia/Blood Disorder

Yes

*Cardiac Irregularities

Yes

*Recent Use of Topical Rx

Yes

*Rosacea

Yes

*Skin Cancer

Yes

*Tattoos

Yes

*Vascular Lesions

Yes

*Drink alcoholic beverages?

Yes

*Consume caffeinated beverages?

Yes

*Exercise?

Yes

*How many cups of water do you drink per day?

*What is your stress level? (1, None – 10, High): _____

4. SKIN CARE HISTORY

Please list skin concerns: (wrinkles, acne, rosacea, etc.)

Please list current medications taken, skin care products, brands and routine: (moisturizers, cleansers, serums, masks, etc.)

*Do you use Retinol (Retin-A)?

Yes

*Have you ever had a facial before?

Yes

What other improvements would you like to see with your skin? (Optional)

Is there anything else we should know about you? (Optional)

5. CLIENT SIGNATURE

Are there any complications and risks associated to Microneedling?

Yes, you might experience scarring, pain, persistent redness, itching and/or swelling, allergic reaction. Although Microneedling is a minimally invasive procedure, there is a risk of infection. It is your responsibility to fully and accurately disclose all medical history prior to any treatment. If you have any condition listed above, if you are taking any medication, and/or if you are allergic to anything, please bring it to the attention of your esthetician prior signing this consent form.

Do you understand Semi-Permanent Results?

Microneedling will not completely or permanently improve skin texture, tone, elasticity, hyperpigmentation, scars, fine lines and wrinkles. It is important that your expectations be realistic, and you understand that the procedure has its limitations. Additional procedures may be necessary to achieve your desired effects.

Unsatisfactory Results

Although rare, there is a possibility Microneedling may induce undesirable results, including but not limited to skin sloughing, scarring, permanent pigment change, and/or other undesirable skin changes. Pigment/color change (hyperpigmentation) is very rare, but could happen due to failure to follow post treatment instructions such as avoid sun exposure for 1 to 2 weeks after treatment, apply daily SPF facial moisturizer, and avoid picking or peeling skin during healing period.

Post-Treatment Instructions

During the first 24 hours it is not recommended to wash the face or use any moisturizers. Mineral make up and sunscreen 50 SPF can be applied the following day. No sun exposure is required for 4 weeks, no sauna nor swimming pool for 1 week. BB Glow Treatment is recommended to be done in series of 3 to 5 sessions, results are accumulative.

Declaration of Consent

I, the undersigned, consent to the use of my pictures and videos taken at the U&I Spa before and after BB Glow Treatment for training purposes, marketing, and social media networking. I understand that I will not be entitled to receive any payment for the use of my pictures or videos pursuant to this declaration of consent.

Acknowledgement

My signature below acknowledges that I have read and understood the content of this consent document. I have been given ample opportunity to ask questions, all of which have been answered in a satisfactory manner. I understand that results can vary from person to person, and no guarantee, neither expressed nor implied has been given to me regarding my results. I am aware of the complications, risks, and benefits of this cosmetic treatment that is not critical to my health.
Of my free will, I am requesting and providing my written consent to undergo a Microneedling treatment and/or BB Glow Treatment at U&I Spa. I assume all risks as my own, and agree to hold harmless U&I Spa, its providers, staff, affiliates, and independent contractors. I hereby release them from any liability, both seen and unforeseen, now and forever.

*Client's Signature

*Date

Parent/Guardian Signature Required if client is under 18

Date