MICRONEEDLING CONSENT FORM Name * First Name Last Name Email * Phone * (###) ### #### Microneedling involves the introduction of fine needles through the skin. The purpose is to create micro-channels in the skin allowing the infusion of active ingredients (such growth factors and hyaluronic acid) to penetrate deeply and effectively into the dermis, nourishing the skin and stimulating the regrowth of collagen. Contraindications include: * ● Keloid or raised scarring. ● History of Eczema, Psoriasis and other chronic conditions. ● History of Herpes Simplex infections. ● Uncontrolled Diabetes (Controlled must have a doctor's consent to move forward) ● Raised moles, warts or raised lesions in targeted areas. ● Patients must be off blood thinners for 3-5 days pre-micro needling ● If on any medications or drugs prescribed by a doctor need to be cleared prior to session ● Pregnancy DO YOU HAVE ANY OF THE CONDITIONS LISTED ABOVE? YES NO If YES, please list: Absolute contraindications include: * ● Scleroderma (hardening of the skin). ● Collagen vascular diseases or cardiac abnormalities. ● Blood clotting problems. ● Active bacterial or fungal infection. ● Immune-suppression diseases. ● Scars less than 6 months old. ● Facial fillers in the past 10 days. ● Warts ● Accutane ● Eczema ● Photosensitivity ● Severe allergies ● Liver disease ● Hepatitis DO YOU HAVE ANY OF THE CONDITIONS LISTED ABOVE? YES NO If YES, please list: Possible side effects: * ● Redness ● Burning/ Stinging ● Dryness ● Flaking ● Track Marks ● Breakouts ● Swelling ● Rash ● Bruising (rare) ● Cold sores (rare) ● Post inflammatory hyperpigmentation (rare) DO YOU UNDERSTAND THERE MAY BE THESE POSSIBLE SIDE EFFECTS? YES NO Collagen Induction Therapy / Micro-needling Pre-Treatment Instructions * Preparing Skin: 1. Use agreed upon gentle cleanser and other products 2. Avoid direct sun exposure or tanning bed at least 4 weeks prior to treatment and during treatment plan process. 3. Do not exercise the day of or for 48 hours after the induction treatment. 4. Avoid caffeine containing food or beverages day of treatment. 5. Avoid medications such as: Aleve, Advil, cold remedies, Vitamin E or aspirin 5 days prior to treatment. 6. Avoid Retin-A, chemical peels, injectable fillers or Botox 2 weeks prior to treatment. 7. Discontinue Hydroquinone, Reinoids, AHA’s, BHA’s, Benzoyl peroxide, and any other possible irritants 3-5 days prior to treatment. 8. Use a sunblock with an SPF 30+ with UVA/UVB Broad Spectrum protection daily. 9. Apply topical anesthetic cream 30 minutes - 1 hour prior to procedure and reapply if necessary. 10. Day of treatment wear comfortable clothing. Your top should button or zip rather than pull over the head. 11. Notify medical professional or Esthetician if you get cold sores. You will require supplement such as Lysine or an antiviral prescription to help avoid any breakout after treatments. 12. If you have open cuts, wounds, abrasions or during active acne or cold sores breakouts, we cannot perform the procedure in those areas. 13. Eat a healthy diet, whole food vitamins and minerals. 14. Drink 8 glasses of water/non-caloric fluids per day. I UNDERSTAND THE PRE-TREATMENT INSTRUCTIONS. YES NO Collagen Induction Therapy / Micro-needling Post-Treatment Instructions * What to be expected: ⬥ Day 1: Skin will be erythematous and flushed after treatment, depending on the intensity of the treatment. Pinpoint bleeding may occur. Do not apply makeup for at least 12 hours. ⬥ Day 2: A red or pink hue persists like moderate sunburn. Swelling and slight bruising may be more noticeable on the second day. Minor scratches may be visible. Apply moisturizer as needed. ⬥ Day 3: Skin can be pink or normal color. Swelling subsides. The skin can feel dry or feel tight. A slight outbreak of acne or milia (tiny white bumps) is possible. Light peeling may occur in roughly three days and will be replaced with brand new skin. Home Care: 1. Gently wash the treated area with a Epionce Milky Ceanser and your fingers only. Gently massage the face with tepid water. Remove serum and other debris such as dried blood. Do not scrub, use a washcloth, or Clarisonic brush. Cleanse treated area twice a day. Do not use exfoliating products for 72 hours. 2. Keep skin hydrated with post-care products provided by the professional who performed your treatment. It is very important to keep the skin hydrated the days following your treatment. New cell regeneration requires at least 6-8 8 oz. glasses of water a day (if you already drink that- consider increasing by 2 glasses) 3. Cool compresses may be applied following treatment for comfort. If neck or décolletage are treated, the redness might last slightly longer. 4. Do not exercise for 24 hours after treatment and avoid strenuous exercise for two to three days after treatment until redness completely subsides. 5. Avoid saunas, steam rooms, hot baths or showers until redness is gone. 6. Continue to avoid direct sun exposure to the treatment areas and apply a broad spectrum sunblock with SPF minimum of 30. Apply it at least 30 minutes prior to sun exposure and repeat after every two hours of sun exposure. 7. After 2-5 days or whenever the redness in the skin dissipates patients can return to regular skin care products or as soon as it is comfortable to do so. Mineral makeup may be applied the following day. 8. Avoid waxing, facials, Botox, injectable fillers or any other skin care treatment 10 days after treatment. 9. If skin becomes painful, swollen, red or inflamed, please notify your skin care professional, as this may represent an infection or allergic reaction that may require treatment. I UNDERSTAND THE POST TREATMENT INSTRUCTIONS. YES NO PLEASE LIST YOUR SKIN CONCERN: * Scars Loose skin Dehydrated skin Enlarged pores Dyspigmentation (due to sun damage and/ or hormonal imbalances e.g. Melasma Fine lines and wrinkles Rosacea By typing my name below and submitting this form, I give my consent to undergo Collagen Induction Therapy (Micro-needling) treatments provided by my licensed professional. I understand this technique involves the introduction of fine needles through the skin. The purpose is to create micro-channels in the skin allowing the infusion of active ingredients (such growth factors and hyaluronic acid) to penetrate deeply and effectively into the dermis, nourishing the skin and stimulating the regrowth of collagen. A series of 4 to 6 treatments are recommended and the frequency will depend on the intensity and depth of the needle. I understand that the treatments require many small injections on the area(s) to be treated. I understand that the administration of numbing creams may be used if deemed needed. Micro-needling is not suitable in these circumstances: ⬥ Have used Accutane (isotretinoin) within the last year. ⬥ Have open wounds, cuts or abrasions on the skin ⬥ Have had radiation treatment to the skin within the last year ⬥ Have any kind of current skin infection, condition, herpes simplex in the area to be treated ⬥ Are pregnant or breastfeeding ⬥ Have any history of keloid or hypertrophic scars or poor wound healing I understand that there are some risks with any procedure. The following are possible reactions with Micro-needling: temporary bruising, skin discomfort during injections, redness or swelling, lightening or darkening of the skin, itching and burning. Skin infection is a possibility any time an injection or surgical procedure is done. Side effects are most of the time temporary and typically resolve within 3 days. Total healing time depends on the depth of the treatment, skin type, and skin condition, and some patients may heal completely in 24 hours. By submitting this form, I certify that I have thoroughly read and understand the contents of this form and the disclosures listed above were made to me. I acknowledge that no promises or guarantees have been made to me as a result of the treatment. I am aware that the results achieved by this treatment may vary from person to person. Some patients typically notice an immediate glow, but visible improvement will take about 2-4 weeks and can continue for up to 6 months. I have read potential risks have been explained to me and I accept them. I hereby give my voluntary consent to have this treatment performed on me. Name: * Thank you!
