Microneedling with SkinPen patient Consent Form
DESCRIPTION OF THE PROCEDURE Microneedling procedures allow for controlled induction of the skin’s self-repair mechanism by creating micro“injuries” in the skin, which triggers new collagen synthesis. The result is smoother, younger-looking skin.
Microneedling procedures are performed in a safe and precise manner with the use of the sterile needle head. The procedure is normally completed within 30–60 minutes, depending on the required procedure and anatomical site.
SIDE EFFECTS After the procedure, the skin will be red and flushed in appearance, similar to a moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on certain areas. This will diminish significantly within a few hours following the procedure. Within the next 24-48 hours, the skin will have returned to normal. After three days, there is rarely any evidence that the procedure has taken place.
CONTRAINDICATIONS Microneedling is contraindicated for patients with: keloid scars, scleroderma, collagen vascular diseases or cardiac abnormalities, a hemorrhagic disorder or hemostatic dysfunction, active bacterial or fungal infection.
PRECAUTIONS AND WARNINGS Microneedling has not been evaluated in the following patient populations, should be taken when determining wheather the Skin Pen procedures is adequate for the patinet: Scars, Strectch marks less than one year old; women who are pregnant or nursing; keloid scars; patinets with history of exzema, psorasis and other chronic conditions; patients with history of actiniv (Solar) keratosis; patients with wound-healing deficiences; patients on immunosuppressive therapy; and skin with presence of raised moles or warts on targeted area.
Patient Consent:I understand that results may vary amoung individuals. I understand that although I amy see a change after my first procedure, I may require a series of sessions to obtain my disired outcome.
The procedure and side effects have been explained, I am advised that though good results are expected, the possiblity and nature of complications cannot be accurately anticipated, therefore, there can be no guarantee as expressed or implied wither as to the success or other result of the procedure is not permananet and natural degradation may occure over time.
The procedure and side effects have been explained to me including alternative methods, as have the advantages and disadvantages.
I state that I have read (or it has been read to me) and I understand this consent and I understand the information contained in it. I have had the opportunity to ask any questions about the procedure including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner.