Scalp Microneedling Consent Form

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Arbitration Agreement *

ARBITRATION AGREEMENT This Agreement is made on date of signature stamp, between Blue Aesthetics Inc, DBA 'Hi Beautiful Aesthetics' of 9400 Westheimer Rd, hereinafter referred to as "First Party" and client named above or signing this agreement virtually, hereinafter referred to as "Second Party." WHEREAS, the business relationship between the parties commenced as dated above by client as defined in the original business contract, which is attached and incorporated herein; AND WHEREAS the parties herein recognize disputes and differences may arise between the parties; AND WHEREAS the parties recognize that litigation in court can be time consuming and expensive; AND WHEREAS the parties agree it is in their best interest to appoint an arbitrator to resolve such disputes as they arise at the cost of client; NOW IT IS AGREED BETWEEN THE PARTIES HERETO AS FOLLOWS: The parties hereto agree to refer the following matters and responsibilities to the Arbitrator and not a lawyer or a court of law: To resolve all disputes and differences under the original contract/consent form, To review the terms of the contract and determine the amount payable by one party to the other, if any To make provisions for the payment of debts and liabilities of the business including income tax liabilities In the event there are any disputes or controversies that arise between the parties pursuant to the terms of the aforesaid Contract, then the parties are waiving their right to litigate these issues in court and instead elect to have these disputes resolved through arbitration. The parties agree that any disputes are to be arbitrated through the American Arbitration Association and that the parties agree to abide by the rules of the Commercial Arbitration Rules of the American Arbitration Association. WHEREFORE, it is agreed that all claims and disputes arising or relating to the Contract are to be settled by binding arbitration in the State of Texas. Said arbitration is to be resolved through the Commercial Arbitration Rules of the American Arbitration Association and the parties agree to abide by these rules. Any decision or award as a result of any such arbitration shall be issued in writing and the arbitrator shall be mutually selected pursuant to the Commercial Arbitration Rules of the American Arbitration Association. Any arbitration award may be confirmed in a court of competent jurisdiction. This Agreement shall be signed by a representative (employee, which is kept on file) on behalf of Blue Aesthetics Inc, DBA 'Hi Beautiful Aesthetics' and by client. I understand & agree this is a legal representation of my signature.

Scalp Microneedling Consent Form

Procedure Overview: Exosome scalp therapy is an advanced regenerative hair restoration treatment that uses stem cell-derived exosomes, which are signaling molecules responsible for tissue repair, regeneration, and cellular communication. At Renovo, we use AnteAGE MDX Hair Solution, a medical-grade, bone marrow-derived exosome product. Exosomes may be injected directly into areas of thinning or microneedled into the scalp to improve absorption and stimulate the hair follicles. Based on your needs, your technician may use one or both methods. Expected Benefits: Activates dormant or miniaturized hair follicles Accelerates regrowth of stronger, thicker hair Improves scalp health, circulation, and hydration Reduces inflammation that can impair hair growth Delivers anti-aging peptides, growth factors, and cytokines Enhances collagen and extracellular matrix repair in the scalp Non-hormonal, non-surgical solution with no downtime Note: Results are best seen with a series of at least 3 sessions, spaced 4 weeks apart, and in combination with prescription medication or at-home scalp treatments. What to Expect During & After Treatment: Your scalp will be cleaned and numbed prior to injection or microneedling. Mild redness, sensitivity, or tingling of the scalp for 24–48 hours is common. Clients may experience minor flaking or itchiness as the scalp regenerates. You should wait 4–6 hours before washing your hair. Resume use of any at-home products the following day unless instructed otherwise. Post-care products, such as a peptide scalp spray, may be recommended to accelerate results. Potential Risks & Side Effects: Although exosome therapy is safe and well-tolerated, possible side effects include: Temporary redness, tenderness, or inflammation at the treatment site Mild flaking or dryness from microneedling Headache or mild irritation Rare: minor bruising, swelling, or infection There is no guaranteed outcome; results vary between individuals Contraindications & Precautions: You should not undergo exosome therapy if you: Are pregnant or breastfeeding Have an active scalp infection or open wound Have uncontrolled autoimmune or inflammatory scalp conditions Are currently undergoing chemotherapy or immunosuppressive therapy Have had an allergic reaction to topical or injectable regenerative therapies (rare) Client Acknowledgment & Consent: Please read and initial each item: ____ I understand that exosome therapy is a regenerative treatment with minimal risks. ____ I understand that results may take several months and vary by individual. ____ I understand that best results occur with a series of sessions and possible combination therapy. ____ I have been informed of potential side effects and post-treatment care requirements. ____ I understand that exosomes may be applied via microneedling, injection, or both. ____ I understand that my technician will determine the best approach for my needs. ____ I have disclosed all relevant medical history and current medications. ____ I consent to before/after photos for medical records and documentation purposes. Consent Statement: I have read and fully understand the nature of Exosome Scalp Therapy. I consent to this treatment using AnteAGE MDX Hair Solution applied by microneedling, injection, or both. I have had the opportunity to ask questions and all concerns have been addressed. I freely consent to receive this service at Renovo Hair Restoration & Wellness.

I agree and have read all the consent forms and I am aware of all complications that can arise. I understand that I will notify my esthetician of any contraindications that may arise. My electronic signature will service as a binding agreement between me and Renovo Hair Restoration & Wellness

Clear