Microneedling Consent Form

Microneedling CONSENT FORM

Personalized Client Consultation
A proper skin consultation is important in any skin care treatment. Avoid clients with rosacea, sunburn and any raised lesions such as keloid scars, moles and active pustules. Review the personalized Plan of Treatment with the client for future visits. Review the personalized Home Care System with the client. Make sure the Client Waiver Form is filled out completely, dated and signed by the client prior to any service. Have the client remove contacts. Take client photos for documentation. * Please read and initial the following:

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INTRODUCTION TO MICRO-NEEDLING The concept of micro-needling is based on the skin's natural ability to repair itself when it suffers physical damage such as cuts, burns, abrasions or other injuries. Immediately after an injury to the skin, our body begins the healing process, triggering new collagen synthesis. The micro-needling device that intentionally creates very superficial "micro-injuries" to the outermost layer of the skin to induce the healing process that includes new collagen production. Micro-needling has been shown to reduce the visibility of acne scars, fine lines, and wrinkles; diminish hyper-pigmentation; and improve skin tone and texture, resulting in smoother, firmer, younger looking skin.
ABOUT THE PROCEDURE Micro-needling is performed using A PEN. The PEN micro-needling procedure is performed in a safe and precise manner with a single-use, sterile needle head. The treatment session usually takes about 30- 60 minutes, depending on the area(s) being treated. Throughout the procedure, activating agents will be applied to stimulate rejuvenation process. Then a hydrating facial mask will be applied for hydration.
After the procedure, your skin will be red with mild swelling and/or bruising, and it might feel tight and sensitive to the touch. Although these symptoms may take 2-3 days to resolve completely, they will diminish significantly within a few hours after treatment.
RISKS OF MICRO-NEEDLING Although the majority of patients do not experience any complications with micro-needling, it is important you understand that risks do exist. The micro-needling procedure is minimally invasive and uses a set of microneedles to inflict multiple, tiny, punctures/lacerations to the outermost layer of the skin. Because microneedling penetrates the skin, it inherently carries health risks, including but not limited to those listed below.
INFECTION - Infection is very unusual. However, viral, bacterial, and fungal infections can occur any time the integrity of the skin is compromised. Should infection occur, you must contact or return to our office immediately, as additional treatment will likely be necessary.
PIGMENT/COLOR CHANGE (hyperpigmentation) - Because the dermal penetration associated with micro-needling is so superficial it doesn't extend into the layer of the skin containing melanocytes, hyperpigmentation is very rare. However, failure to follow post-treatment instructions can put you at risk for hyperpigmentation. ____ You MUST avoid sun exposure for 1 to 2 weeks after a micro-needling treatment. You should also wear a daily SPF facial moisturizer, which your practitioner can recommend.
Lastly, avoid picking and/or peeling the skin during the healing period.
Although normal healing after the procedure is expected, abnormal scars may occur in both the skin and deeper tissues. In rare cases, thickened or keloid scars may result, especially if you are prone to keloid scarring anyway. Scars may be unattractive and of different color than surrounding skin. Additional treatments may be needed to treat scarring.
PAIN - There may be a very slight burning, scratchy, and irritated sensation to the skin. This is usually temporary and is gone within a few hours after treatment. A sudden reappearance of redness or pain is a sign of infection, and you should notify our office immediately.
PERSISTENT REDNESS, ITCHING, AND/OR SWELLING - Itching, redness, and swelling are normal parts of the healing process. These symptoms rarely persist longer than 24 hours. However, treatments received less than 4 weeks apart may induce prolonged symptoms.
ALLERGIC REACTION - Micro-needling is performed with a device whose head contains 9-12 sterile, hypodermic needles, which makes an allergic reaction nearly impossible. However, in conjunction with the micro-needling procedure a variety of products may be used on the face; those products could cause an allergic reaction. Additionally, since micro-needling increases the penetration of topical substances, it could cause you to become hypersensitive to products used on the face. *If an allergic reaction were to occur, you must contact our office immediately, as it may require further treatment.
LACK OF PERMANENT RESULT - Micro-needling will not completely or permanently improve skin texture, tone, elasticity, hyperpigmentation, or scars, or minimize 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 effect.
UNSATISFACTORY RESULT -Although rare from micro-needling, there is a possibility of a poor result from any cosmetic procedure. Micro-needling may induce undesirable results, including but not limited to skin sloughing, scarring, permanent pigment change, and/or other undesirable skin changes. There is always a possibility that you may be disappointed with the final results of micro-needling.
CONTRAINDICATIONS TO MICRO-NEEDLING Although it is impossible to list every potential risk and complication, the following are recognized as known contraindications to micro-needling. Furthermore, it is your responsibility to fully and accurately disclose all medical history prior to initial treatment, as well as to provide any necessary updates at all future treatment sessions. If you have any of the conditions listed below, you should bring it to the attention of your esthetician or healthcare provider PRIOR to signing this consent form. Active acne Hemophilia / bleeding disorders Scleroderma
Active infection of any type (bacterial, viral, or fungal) Hormone Replacement Therapy, Skin Cancer, Blood thinner medications, Keloid/hypertrophic scarring, Sunburn, Cardiac disease/abnormalities, Raised lesions (moles, warts, etc.) Tattoos, Chemotherapy or radiation, Recent chemical peel procedure, Telangiectasia/erythema Collagen Vascular Disease, Recent use of some topical Rx., Uncontrolled diabetes, Eczema, Psoriasis, or Dermatitis, Rosacea, Vascular lesions (hemangiomas)

Frequency of Treatments: Due to the intensive exfoliation, without irritation to the skin, Micro-needling is recommended as follows:

* For All other skin types- 4-6 treatments at least 3-6 weeks apart. * For Acne skin types- Once every two weeks until the acne is under control. * Maintenance treatments- Every month to maintain the integrity of the skin.
Over microneedling can cause undue sensitivity to the skin's surface leaving the skin red and blotchy.
Post Care for Micro-Needling: Make up may be applied upon completion of the treatment.
Avoid exfoliants for 2-3 days after treatment due to sensitivity and redness. Always .use sunblock when outdoors.

My signature below acknowledges that I have read and understand the content of this informed 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 and that no guarantee, neither expressed nor implied, has been or will be given to me regarding my results. I'm aware of the risks and benefits associated with the Micro-needling procedure, as well as available alternative treatments. I understand that micro-needling is an elective procedure performed solely for cosmetic purposes and is not critical to my health. Of my own free will, I am requesting and providing my informed consent to undergo Micro-needling treatment(s) at Elmira Studio . I assume all risks as my own and agree to hold harmless, Elmira Studio , its providers, estheticians, and any other staff members, affiliates, and independent contractors. I hereby release them from any liability, both seen and unforeseen, now and forever.

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