Microneedling Collagen Induction Therapy Waiver

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1. Full Name* This field is required.

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2. Are you pregnant or breastfeeding?* This field is required.

Yes - Unfortunately, you are not a candidate

No

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3. Are you prone to keloid scarring?* This field is required.

Yes - Unfortunately, you are not a candidate

No

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4. Do you have diabetes?* This field is required.

Yes - Unfortunately, you are not a candidate

No

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5. Have you taken Accutane or similar in the last 6 months?* This field is required.

Yes - Unfortunately, you are not a candidate

No

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6. Do you have an active cold sore or HSV breakout anywhere near the treatment area?* This field is required.

Yes - Unfortunately, you are not a candidate.

No

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7. Do you have any active inflammatory skin conditions, ie hives, rashes, active acne or infections?* This field is required.

Yes - Unfortunately, you are not a candidate

No

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Please note that if you are prone to cold sores, you must be on Valtrex or similar 2 weeks prior to microneedling in order to best prevent a breakout after receiving the treatment.

If you have active acne, we cannot perform microneedling. The microneedling would spread the acne causing bacteria and make your breakouts worse. Microneedling is best performed once acne is under control to combat any scaring that acne has left behind. If acne is your concern, please book the Acne Calming Facial.

Depending on the area of your face or body being treated and the type of device used (i.e. needle length), the procedure is well-tolerated and in some cases virtually painless, feeling only a mild prickling sensation. Your practitioner will apply a topical anesthetic to your skin prior to treatment to reduce any pain and discomfort.

Side effects or risks are minimal with this type of treatment and typically include minor flaking or dryness of the skin with scab formation in rare cases. Milia (small white bumps) may form. Hyper-pigmentation (darkening of certain areas of the skin) can occur very rarely and usually resolves after a month. If you have a history of cold sores, this procedure may cause flare ups. Temporary redness and mild-sunburn effects may last up to 4 days. Freckles may temporarily lighten or permanently disappear in treated areas. Other potential risks include: crusting, itching, discomfort, bruising, infection, swelling, and failure to achieve the desired result. Permanent scarring (less than 1%) is extremely rare.

The benefits and risks of the procedure have been explained to me, and I accept these benefits and risks. The nature of my medical or cosmetic condition has been explained to my satisfaction as have been any substantial or significant risks of harm. I am also aware of and accept the risk of rare and unforeseen complications which may not have been discussed and which may result from this treatment.

I have had/will have the opportunity to ask questions and seek clarification of this procedure and its alternatives including no treatment and my questions have been/ will be answered satisfactorily. I understand the following contraindications listed below and will notify my provider if any of the following apply to me:

Active infections - viral, fungal, bacterial

Rashes, warts, skin cancer

Skin-related autoimmune disorders

Pregnant or breast-feeding

Patients on anticoagulants (NSAIDS, ASA, Coumadin/Warfarin)

Recent ablative dermal procedures

Actinic (solar) keratosis Keloid Scarring

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Please Sign Here* This field is required.

I agree to use electronic records and signatures.

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I hereby authorize Jamee Mittell Esthetics Studio or any delegated associates to perform Microneedling (Collagen Induction) Therapy. I understand that this procedure is purely elective.* This field is required.

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