Microneedling Wavier Form

Name*

First NameLast Name

Email*

example@example.com

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Phone Number*

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I have received a consultation with a Skin Care Specialist and I consent to the treatment of Microneedling to be carried out upon myself. The Microneedling treatment allows for controlled induction of growth factor serums, or hyaluronic acid, into the skins self-repair process by creating micro injuries in the skin. These injuries stimulate new collagen production, while not posing the risk of permanent scaring. The result is smoother, firmer and younger looking skin. The skin needling treatments are performed in a safe and precise manner with a sterile needle head and are usually completed in 30-45 minutes.*

Initial

Absolute Contraindications: Scleroderma, collagen vascular disease, or cardiac abnormalities, rosacea, blood clotting problems, platelet abnormalities, anticoagulation therapy (i.e.: Warfarin), facial cancer, past and present, chemotherapy, steroid therapy, dermatological diseases affecting the face (i.e. Porphyria), diabetes and other chronic conditions, active bacterial or fungal infections, immune-suppression, scars less than 6 months old and facial fillers in the past 2-4 weeks. Treatment is not recommended for patients who are pregnant or nursing.

Precautions: keloid or raised scarring, eczema, psoriasis, actinic keratosis, and herpes simplex.

Side Effects Typically Include:

Skin will be pink or red and may feel warm, like mild sunburn, tight and itchy, which usually subside in 12 to 24 hrs.
Minor flaking or dryness of the skin, with scab formation in rare cases.
Crusting, discomfort, bruising and swelling may occur.
Pinpoint bleeding.
It is possible to have a cold sore flare if you have a history of outbreaks.
Freckles may lighten temporarily or permanently disappear in treated areas.
Infection is rare but if you see any signs of tender redness or puss notify our office immediately.
Hyperpigmentation (darkening of the skin) rarely occurs and usually resolves itself after a month.
Permanent scarring (less than 1%) is extremely rare.

I have been informed about the treatment, procedure, indications, expected results and possible side effects. I understand that I am required to have photographs taken before, during and after treatment for my records. Although the results are usually dramatic I have been informed that the practice of medicine is not an exact science and that no guarantees can be or have been made concerning the expected results in my case. I am undergoing treatment of my own freewill. I agree that this procedure is being performed for cosmetic reasons. I am also aware of and accept the risk of unforeseen complications that may not have been discussed and which may result from this treatment. I acknowledge my obligation to follow the instructions closely and visit the office as directed. I certify that I have read the above consent agreement and fully understand it. These items have been reviewed and discussed with the skincare specialist and all my questions have been answered to my satisfaction. I also agree to hold harmless and release from any liability of Ashley Lynn Esthetics or any of its officers, directors and / or employees for any condition or result, known or unknown that may arise as a result of any treatment that I receive. I am also aware that if I purchased a package of sessions they must be used accordingly how it states on the booking app where I made my appointment. *

Date*

Date