MICRONEEDLING Consent FORm * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Do you give consent for microneedling treatment to be performed on you? * Yes No Please read and initial each of the statements below: I certify I am over the age of 18. * I understand that MicroNeedling treatment treats all conditions on the face from fine lines and wrinkles, acne, scarring, sun damage and enlarged pores * I understand that active products are used on the skin during the treatment due to the microchannels created will allow my skin to carry up to 80% more active ingredients, which dive deep into the skin to feed and be absorbed by the underlying cells. * CONTRAINDICATIONS Please read and check any of the contraindications for the Microneedling treatment that may apply to you. If none apply to you please check the last box. * Active acne or other skin infections Rosacea or eczema flare-ups Open wounds, cuts, or abrasions on the treatment area History of keloid scarring Use of certain medications that affect skin sensitivity or healing, such as isotretinoin (Accutane) Pregnancy or breastfeeding History of skin cancer or current treatment for skin cancer Autoimmune disorders or compromised immune system Active cold sores or herpes simplex virus outbreaks Recent use of topical retinoids or exfoliating agents Hemophilia, blood clotting problems (ie poor wound healing) Solar Keratosis Connective tissue disorders / auto immune disorders (e.g. lupus) Long term use of Prednisone and other steroid medications (treatment will increase inflammation) HIV/AIDS Anticoagulants / Blood thinners (including but limited to Warfarin or aspirin) Nickel or stainless steal allergies Scleroderma Collagen vascular diseases Allergic reactions to topical anesthetics or numbing agents used during the procedure Active inflammatory skin conditions, such as psoriasis or dermatitis Uncontrolled diabetes N/A: I do not have any of the listed contraindications Transplant Anti-Rejection Drug; Heart Disease; Hypertension (High blood pressure treated with medication); Cancer - after 12 months; Insulin Dependent Diabetes * The contraindications stated above, are all conditions that need a doctor's letter to confirm the treatment is suitable before the Microneedling treatments can begin. Prior to the microneedling procedure, I have been advised to: * Check all to confirm you understand Avoid direct sun exposure and tanning beds for at least 1-2 weeks before and after the procedure. Discontinue use of retinoids, exfoliating agents, and other potentially irritating skincare products for a specified period before the treatment. Inform the esthetician of any medical conditions, allergies, or medications I am currently taking. Follow post-procedure care instructions provided by the esthetician, including the use of recommended skincare products and sun protection. I understand that microneedling may involve certain risks and potential side effects, including but not limited to: * Check all to confirm you understand Temporary redness, swelling, or bruising Mild discomfort or pain during the procedure Skin sensitivity or irritation Post-inflammatory hyperpigmentation Infection or scarring (rare but possible) Allergic reactions to topical products used during the procedure The list below is of things that require a waiting period until you can start treatments: * Wait until completely clear and healed - Active bacterial, fungal or viral skin infection of any type in the area to be treated - Active Herpes – cold sores — (even if inactive take anti-viral medication 2 weeks pre and post treatment (peels & needling) - Warts in area to be treated - Sunburn in the treatment area - Inflammation - Open Lesion on area to be treated Waiting times for specific procedures (on area to be treated) - Recent facial operations - At least 3 months post surgery - Isoretinoin (e.g. Roaccutane) - 6 - 12 months post treatment - Tattooing / Cosmetic Tattooing – 3 months - IPL / Laser hair removal – 2 weeks - IPL skin treatments - 2 weeks - Laser Resurfacing/Ablative – 8 weeks - Strong chemical peels - PH lower than 3.1. – wait 2 weeks - Botulinum Toxin - 2 weeks - Dermal Fillers – Hyaluronic Acid & Vital Hydrate – 2 weeks - Dermal Fillers - Sculptra & Radiesse - 6 week Stop using/taking 1 week before commencing treatments: - Fish Oils / Plant oils / Omega 3s - Ginseng / Gingko Biloba / St Johns Wart - Retinoids - Topical antibiotics - Exfoliants and/or AHA or BHA - Benzoyl peroxide / adapelene (Differin) - Hydroquinone / kojic acid / azelaic acid - Anti-inflammatory medications such as ibuprofen. These will interfere with the natural inflammatory process that is critical for your skin rejuvenation. - Waxing or depilatory creams on the area to be treated Recovery Time • 60 minutes: Reddening and possible pot bleeding • Up to 24 hours: Erythema (reddening or rash like appearance) , Petechiae (pinpoint, round spots), minor oedema (swelling) • 1-2 days: Mild erythema , petechiae, reduced oedma, minor itching, dry/tight sensation. • 2-3 days Reduced erythema, fading petechiae, dissipated oedema, reduced itching, minor skin flaking • 3-4 days: Potential dryness • 4-5 days: Full Recovery with normal function • 3weeks: improved pigmentation begins • 4-6 weeks: Improvements in lines, wrinkles and scarring begins Please avoid the following activities for up to 2 days following a microneedling clinical procedure: • Direct ultra violet exposure (sun and sunbeds) • Intensive cardio, exercise or gym regimens • Excessively hot showers, bathing, spas or sauna • Swimming in chlorinated pools or the ocean • Tattooing (including cosmetic tattooing) • Further clinical treatments (including, but not limited to): microdermabrasion, laser, intense pulsed light, chemical peels, muscle relaxant injections and dermal fillers) should be avoided for up to two weeks. Please avoid the use of skin care products containing any of the following active resurfacing ingredients for up to 5 days following a microneedling clinical procedure: • Alpha hydroxy acids (AHAs) (including but not limited to) glycolic, lactic or malic acid • Beta hydroxy acid (BHA) including salicylic acid • Benzoyl peroxide • Retinoids (including but not limited to) tretinoin, retinol and retinaldehyde • Hydroquinone • High levels of Kojic or azelaic acid • Alcohol (including but not limited to) isopropyl alcohol/de-natured alcohol/rubbing alcohol Do not apply spray tans or fake tan creams for 2-3 weeks after the treatment If in doubt with any of the above activities or products, please contact us for clarification to when normal activity or use may be resumed. HOMECARE Avoid exercising, sauna, steam room for 48 hours after treatment. Avoid anything that will cause you to sweat. For the first 1-3 days the skin may feel tight and dry. Keep your skin moisturized. Light, non-occlusive and non-comedogenic make-up may be applied 24 hours post-procedure and a SPF is advised for at least 3 days after your treatment. After 2-3 days you can return to your regular skin care products with the exclusion of the products listed above Low doses of Vitamin A products are recommeneded Avoid direct sunlight and always wear SPF30 or above. Do not apply a chemical sunscreen the same day as the treatment, only approved physical defense sunscreen can be used. Microneedling serves to stimulate collagen and the skin can benefit from higher amounts of collagen than normal to have optimal results. Collagen stimulating peptides assist in this process. It's important to hydrate before and after the procedure to help skin heal and rejuvenate faster. I understand that my technician only utilizes sterilized, disposable equipment to minimize the risk of infection or contamination and that my technician has received training inappropriate sanitation and hygiene techniques prior to performing any procedures. While the risk of infection from our procedures is extremely small, the possibility of such an occurrence cannot be totally prevented. Accordingly, I understand and accept the risk and release my technician and the spa from any and all liability related to the subject procedure, except instances involving gross negligence. * I grant permission to take and use: photographs and/or digital images of me for use in news releases, educational materials and/or social media platforms including but not limited to Instagram, Facebook, Twitter, Tic Toc, and Pinterest. * By signing below, I agree to the following: I have read or have had read to me the contents of this whole form. I understand the risks and alternatives involved in this/these procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. I accept full responsibility for the decision to have microneedling treatment done and understand that there is a no refund policy. I acknowledge that I have reviewed and approved the material given to me. * Date MM DD YYYY Thank you!
