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Collagen induction therapy ~ consent form
Collagen Induction Therapy ~ Consent Form
You must be 18 years of age to be treated with Collagen Induction Therapy (CIT) , or have a parent or legal
guardian sign the form with you, giving consent for the treatment.
Please initial that you have read each of the below statements:
_____ You have the right to be informed about this treatment and decide whether or not to proceed.
_____ Photos may be taken and are the property of Face Place, and it’s owner/agents.
_____ Treatments help stimulate the skin to generate new skin cells, collagen & elastin, allowing the skin
to become smoother and refined. Immediate results should not be expected, as it takes days to weeks for
the skin to develop new tissue. The skin of the face is living and responds to treatment, however, each
individual responds differently. A series of treatments will bring the most improvement.
_____ It is understood by my signature below that I hold Face Place and it’s trained technician(s)
performing the treatment harmless from any skin condition that I currently have or that may develop in
the future regardless of the treatments(s) performed on my behalf.
_____ Any change in my health, occurrence of pregnancy, medical condition, or prescription
medications will be reported to my CIT professional for consideration prior to skin treatments.
_____ I understand there are no guaranteed results
Please read and initial each of the below statements:
____ I have no known allergies. If so, list here _____________________________________
____ I understand that I must verbally inform my technician of any concerns, use of medication
(including aspirin or other pain medications) or medical conditions prior to receiving CIT treatments even
though it is noted on the Medical History Form.
____ I understand that if I do have a medical condition, or any allergies that would contraindicate the
CIT treatment, the technician can make a decision to ensure my safety and refuse CIT treatment on my
____ I am not under the influence of alcohol, drug or any other substances.
____ I release Face Place and its subsidiaries and representatives of all claims for injury; seen or unseen
that may occur as a result of CIT Treatment.
____ I understand that no promise has been made to me as to the final result of the treatment I have
____ I understand there are possible risks involved, and these have been explained to me prior to
____ I understand that there may be some discomfort during the procedure.
____ I understand that there may be some discomfort during the healing process.
____ I understand there is a possibility of swelling, bleeding and allergic reactions to the anesthetics, or
the topical cosmetic products used during or after the procedure.
____ I have be given the opportunity to address all of my questions and concerns about the risks,
hazards, and aftercare for the treatment being performed with my consent.
____ Although noticeable results may be obtained with a single CIT treatment, the greatest improvement
will be seen after a series of 3 to 5 consecutive treatments. The CIT treatment can safely be performed 4 to
6 weeks apart until the desired result is achieved.
Please acknowledge each of the following Client Responsibilities by initialing the following:
You cannot have the CIT needling procedure - if you have a history of or are:
___ acute infection or inflammation of the skin
Collagen Induction Therapy ~ Consent Form
Aspirin, Nurofen, Vitamin E and all blood thinning drugs all cause increased bruising. For this reason it is
advised that you abstain from taking them prior to treatment. Optimally two weeks prior to treatment,
however 3 days prior is acceptable. If you do not abstain, you may experience more bruising and transient
swelling in the treatment area more severely, causing a longer time for skin recovery.
If prone to Cold sores or Herpes Simplex, you will need to take an anti-viral drug such as Zovirax, Famvir,
Valtrex or another prescribed by your Physician. Take the medication as prescribed for 1 week prior and
one week after CIT of the lip or face.
After treatment you will experience redness, swelling and irritation. You may feel like you have a mild
As a Client you are responsible to inform your technician of any possible concerns. Please call your
therapist with any concerns after the treatment, that you may have as well.
Please read and initial each of the following statements:
____ I acknowledge that I have been given a copy of this Consent Form prior to the Collagen Induction
Therapy (CIT) treatment performed, and have attain reasonable understanding of this Consent Form.
____ I completely understand the terms, questions, and conditions of the Disclosure and Consent Form,
and my questions and concerns have been answered.
____I confirm that this Disclosure and Consent Form was filled out completed by me and that all information provided is true and completed to the best of my knowledge.
Signature: __________________________________________________ Date: _____________________
Legal Guardian Signature: _____________________________________ Date: _____________________
Esthetician Signature: _________________________________________ Date: _____________________
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