consent form microneedling english

• Your skin may feel warm, tight, and itchy for a short while. This should subside in 12-48 hours.

• Your skin will be pink or red in appearance, much like sunburn, for a couple of hours following treatment. Minor bleeding and bruising is possible depending on the length of the needle used and the number of times it is pressed across the treatment area.

• Possible Side-Effects:

a) Side effects or risks are minimal with this type of treatment and typically include minor flaking or dryness of the skin with scab formation in rare cases.

b) Milia (small white bumps) may form

c) Hyper-pigmentation (darkening of certain areas of the skin) can occur very rarely and usually resolves after a month.

d) If you have a history of cold sores, this procedure may cause flare ups.

e) Temporary redness and mild-sunburn effects may last up to 4 days.

f) Freckles may temporarily lighten or permanently disappear in treated areas.

g) Other potential risks include: crusting, itching, discomfort, bruising, infection, swelling, and failure to achieve the desired result. Permanent scarring (less than 1%) is extremely rare.

I understand the following contraindications listed below and will notify my provider if any of the following apply to me:

a) Active infections - viral, fungal, bacterial

b) Rashes, warts, skin cancer

d) Immune-suppressed patients

e) Skin-related autoimmune disorders

f) Pregnant or breast-feeding

g) Patients on anticoagulants (NSAIDS, ASA, Coumadin/Warfarin)

h) Recent ablative dermal procedures

k) Actinic (solar) keratosis

• Alternatives to the procedures and options that I have volunteered for have been fully explained to me.

• Client experiences may vary.

• Any contraindications will void this treatment

• This treatment cannot be transferred to another person

• Once the injection has been given, refunds are prohibited

• Appointments preferences are based on availability

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

• Pre and post treatment instructions have been explained to me

• I have had sufficient time to consider the Cellfina® treatment and had the opportunity to ask questions, and all of my questions have been answered to my satisfaction and understanding

• Must notify the clinician if my medical history changes prior to subsequent treatments

• I consent to clinical photographs being taken of my treated areas for my personal health record only

• My signature below constitutes my acknowledgment and understanding of all this information