Microneedling / Collagen Induction Therapy Informed Consent
I understand there is no guarantee that can be given to me as to the condition of my skin or degree of improvement expected in the following treatment, that multiple treatments and the use of the recommended home skin care maintenance are required to achieve optimal results. I am not pregnant or lactating and I have told the medical staff about any allergies.
You are eligible for micro-needling if the following applies to you:
- Lack of skin radiance, loss of elasticity and epidermal thickness, rough and uneven skin texture
- Fine lines, Wrinkles, Crow’s feet
- Hyperpigmentation, melasma Scars, especially indented acne or chicken pox. Post surgical Scars
- Skin Dullness, Dry Skin
You are NOT eligible for micro-needling if the following applies to you:
- This treatment should not be used on patients with active skin cancer or active bacterial, fungal or viral (i.e. herpes, warts) skin infections in the procedure area(s). NOTE: This product
is not intended for transdermal (under the skin) delivery of cosmetics.
- You suffer with active pustular acne, Active bacterial, viral or fungal infections
- Eczema, Psoriasis, Rosacea, Actinic (solar) keratosis or Diabetes
- Keloid or raised scars or scars less than 6 months old, presently using isotretinoin (Accutane)
- Raised moles or warts, had facial surgery in the past 6 months
- Patients taking blood pressure, blood thinning or heart medications or Immunosuppression
Side Effects
After the procedure, the skin will be red and flushed in appearance in a similar way to moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on the area being treated. This will diminish greatly after a few hours following treatments and within the next 24 hours the skin will be completely healed.
I understand that results will vary among individuals. I understand that although I may see a change after my first treatment, I will likely require a series of sessions to obtain my desired outcome. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that micro-needling treatment is not permanent as natural degradation will occur over time. I state that I have and I understand this consent and the information contained in it. I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner.
I have read the above information and I fully understand what to expect. I give permission to my skin therapist to perform the micro-needling procedure we have discussed and will hold her, medical director and staff harmless from any liability that may result from this treatment. I understand she will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions, as much as possible. I have given an accurate account of any over-the-counter or prescription medications that I use regularly. I am not ingesting or using topically any other over-the-counter product or prescription medication that has not been disclosed to my therapist. I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn, or broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a history of keloid scarring, excessive telangiectasia, viral infections, open lesions or rashes, active acne, any autoimmune disease, or any other existing condition that may interfere with the positive outcome of this treatment.