SQT CLIENT FORM

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Client Name

First

Last

Date of Birth

Address line 1

Address line 2

Contact Number

What would you like to achieve from your treatment?

2. Skin concerns

RESURFACING SET : ACNE, PIMPLES, BLACKHEADS, WHITEHEADS, SKIN MARKS, LARGE/OPEN PORES, OILY SKIN
REVITALISING SET: ANTI-AGEING, FINE LINES, BLEMISHES, PIGMENTATION, MELASMA, DRY SKIN, DULL SKIN

3. Do you have any specific skin concerns pertaining to your face or body? Yes / No, please specify:

4. Have you had any skin treatments in the last month? Yes / No – if yes, please specify when:

5. Have you used or received any treatment with retinol, retinoids or vitamin A products in the last month? Yes / No – if yes, please specify what product and how often:

6. If you answered yes to the question 4 or 5, did the treatment occur within the last three months?

7. Have you ever used any prescribed acne medications? Yes / No – if yes, please specify what product and how often:

8. What skin care products are you currently using? Please list brand if known (soap, cleanser, masks, moisturiser, toner, eye product, exfoliator, sun protection)

I give permission for my skin therapist, to perform the Bio-microneedling treatment we have discussed and will hold him/her and his/her staff harmless from any liability that may result from this treatment.

I consent

I understand my skin therapist will take every precaution to minimise or eliminate negative reactions as much as possible. I do understand that, very rarely, permanent damage occurs (none reported). I have given an accurate account of any over-the-counter or prescription medications that I use regularly and I am not presently using (nor have I used within the six months) Accutane.

I consent

I have not had any facial surgical procedures, piercings, tattoos, permanent cosmetics, or other chemical peels or skin treatments that I have not disclosed to my skin therapist. I am not ingesting or using topically any other over-the-counter product or prescription medication/agent that has not been disclosed to my skin therapist.

I consent

I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn or broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a history of any auto immune disease, current active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment.

I consent

I understand that I should not have a bio-microneedling treatment if l intend to continue to have excessive sun exposure. It has been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and will require regular use of sunscreen.

I consent

I consent to the taking of photographs by my therapist to monitor treatment effects and potentially used for marketing and training purposes.

I consent

My expectations are realistic and I understand that the results are not guaranteed and that for maximum results, more than one application may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/environmental damage, pigmentation levels.

I consent

I understand that this procedure is expected to make the skin feel temporarily uncomfortable while being applied, but agree to inform the skin professional immediately if I have concerns or am overly uncomfortable during treatment or after I return home.

I consent

I agree that I am willing to follow recommendations by my therapist for home care. I will be responsible for following home protocols that can minimise or eliminate possible negative reactions, including recognising the importance of adhering to a sunscreen and avoiding the sun/tanning beds and extreme weather conditions. I agree to use a moisturiser specifically recommended by my therapist and I acknowledge that I have been informed of the possible negative reactions (intense erythema, blisters, scabs) and the expected sequence of the healing process (tingling, heat, dryness, irritation, redness, and peeling of the skin). In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my therapist immediately.

I consent

I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I have read the above information and initialled each section to indicate that I fully understand what to expect. If I have any questions or concerns, I will address these with my skin therapist.

I consent

Symptoms after SQT Sponge Spicules Bio-Microneedling Treatment (Please check the box if you have read and understand)

What may happen after sponge spicules therapy (depending on the individuals constitution):
RED: Most people will be red for 1-2 days. It is a normal reaction that senescent cells are metabolised. DRY: The skin will be relatively dry for a few days after doing SQT and may need supplementary moisture.M
ITCHING: Itching can indicate that the dirt in the skin has not been discharged. Under the action of sponge spicules therapy, the speed is accelerated. The itching is also an sign that the skin is generating new cells. You can pat very gently with pure water or a suitable misting product instead of touching with your hands
PEELING: Due to the accumulation of old keratinous skin, there will be varying degrees of stratum corneum renewal and peeling.M
PURGING: For skin prone to pimples, closed acne may appear on the third day which is normal.

Post Treatment/Home Care (Please check the box if you have read and understand)

Lightly cleanse your face with clean water for 2 days after SQT® Sponge Spicules therapy.
Use a mild cleanser for 3 to 5 days after using SQT® Sponge Spicules.
Prohibit using alcohol based soap, or any other exfoliating products and products with pellet/grain or active ingredients.
Apply SQT aftercare without alcohol and essential oil content.
You can pat the skin with the recovery serum or you can use Avene Thermal Spring Water spray to soothe.
Do not scratch or pick the dry and itchy areas to avoid risk of scaring. Peeling may appear on the third day after treatment, do not peel off forcefully. Instead, try moisturising the skin.
If you remove dead skin cells forcefully, you may cause scarring.
Make sure to protect the skin and avoid sun by the physical way or apply non-irritating sunscreen as the skin is very sensitive to UV rays after the procedure. (Freckles or pigmentation might occur when skin is exposed to the sunlight without applying sunscreen.)
I understand that I must follow post care advice to get the best results from my Biomicroneedling Treatment.

Client Name

Signature

Date

Date of under the skin consult in clinic where everything has been discussed per this form.

I have informed my client on all the above information.

Therapist Signature

Date