Microneedle Consent Form

Microneedle Consent Form

Native Beauty Medical Esthetics LLC
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Clinically proven benefits:

Wrinkle Treatment

Within 150 days of procedure, 4 treatments spaced 4 weeks apart showed a significant improvement in wrinkles.

Acne Scar Treatment

4 treatments spaced 4 weeks apart showed a significant improvement in acne scarring, 24 weeks after treatment series

Other possible benefits:

Reduction in pore size

Evening skin tone discolorations

Improvement with melasma

Healing stretch marks

Flattening surgical scars
Post treatment care:
- Use a gentle cleanser and moisturizer daily for 3 days, you can continue normal skin care routine after that with active serums.
- Use a clean pillow case the night of treatment.
- Avoid sun and tanning for 2 weeks.
- Wear SPF daily while undergoing treatments.
- Do not sweat or exercise for 72 hours.
- Do not go swimming for 72 hours.
The treatment will not be performed on the following conditions unless approved by your medical provider, please check any that apply to you.

Hemophilia or other blood clotting disordersUnregulated diabetesPregnancy and nursing mothersSystemic infection or acute local infections (hepatitis disorders A,B, C, D, E, F or HIV infection.High doses of anti-coagulants or blood thinning medications such as aspirin, warfarin, acetylsalicylic acidIsotretinoin or accutane in the last 6 monthsInflamed acne in treatment areaPatients on high dose of chemotherapy, radiotherapy, or high dose corticosteroid therapyAllergy to topical anestheticAllergy to stainless steelEczema in treatment areaPlastic surgery of the face, dermal fillers in the last 12 months or facial surgical scars under 12 months old.Botox or filler in the last 2 weeks.Scars less than 6 months old in treatment areaAreas of skin dermatosis e.g. Birthmarks, keloidal scarring, skin tumors, solar keratosis, warts
Risks associated with this procedure
- localized bleeding in the treatment area stopping within 5-10 minutes
- Pain during treatment. Moderate-severe pain.
- Pain and discomfort on the first day after treatment
- Non-persistent inflammatory response, erythema and edema in the first one to six days after treatment
- Skin irritation (e.g. itching or warming), which normally abated within 8 days.
- Temporary flaking or peeling of the skin, which clears after 8 days
In addition to the common non-serious side effects, the following side effects have been reported:
- Blisters caused by herpes simplex virus type 1. Anti-viral is recommended.
- Formatuin if small pustules or milia within the first days after treatment
- Hyperpigmentation with endogenous pigments, in particular on darker skin types, but which generally disappear completely after a few weeks.
- Persistsnt inflammatory response, hematoma, erythema, and edema lasting longer than 5 days.
- Retinoid reaction (slight reddening to skin peeling.)
- Headache within the first 2 days after treatment
- Fever within the first 3 days after treatment.
I consent to Native Beauty taking my photos for tracking my personal progress.

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I consent to Native Beauty using my photos for advertising purposes.

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My provider has thoroughly gone through the benefits as well as risks and complications with me.
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