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Microneedling Consent
Microneedling Consent
Name
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Last
Date
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Consent
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I acknowledge the following
I understand that in rare cases, micro-needling may cause infection, pigment/color change, scarring, pain, persistent redness, itching, and/or swelling, and/or an allergic reaction.
I understand that after the procedure, the skin will be red, with mild swelling and/or bruising, and 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.
I understand there are certain contraindications that would prevent me from receiving micro-needling treatments including active acne, active infection of any type (bacterial, viral, or fungal), eczema, psoriasis, or dermatitis, hemophilia/ bleeding disorders, keloid/hypertrophic scaring, pregnancy/lactation, raised/open lesions (moles, warts, etc.), skin cancer, sunburn, tattoos, telangiectasia/erythema, uncontrolled diabetes, and scleroderma.
I understand that the use of Botox®, Juvederm®, Restylane®, and any other injectable must be disclosed prior to treatment.
I understand that there are some contraindicated medications: blood thinner medications, chemotherapy or radiation, hormone replacement therapy, recent use of some topical medication.
I understand that micro-needling is contraindicated within 72 hours of waxing, and within 3 weeks of a chemical peel.
I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.
I understand that I MUST avoid direct sun exposure for 72 hours after a micro-needling treatment. I should also wear a daily SPF.
I understand that I must discontinue retin-A products, Vitamin A products, and/or topical acne medications at least 5-7 days prior to treatment.
I understand that I must be off of Accutane 6 months prior to receiving any microneedling treatments.
I understand that I've been advised a series of treatments are recommended to achieve maxium benefits from microneedling. I also understand that I cannot expect to see the same results with one treatment that I would see with a series of 4 or more etc.
The nature and purpose of the treatment have been explained to me. I have read and understand this agreement in its entirety. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.
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