You are receiving a series of microneedling treatments, which are medical-aesthetic services delegated to a licensed esthetician who is not a licensed healthcare provider.  These services are performed under the supervision of a licensed medical professional.

Supervising Medical Director:  Jonathan Gallen, M.D.

License # DR.0048208

Email: jonathan.gallen@yahoo.com

If you have concerns about your care, you may contact the Medical Director directly.  You may also contact the Colorado Department of Regulatory Agencies at:

https://dpo.colorado.gov

Email: dora_barber-cosmetology@state.co.us

The treatments will be in a series of 3. The patient and esthetician will determine the timing intervals between treatments.

Risks and Benefits 

Microneedling involves the use of fine needles to create micro-injuries in the skin, stimulating collagen production. Risks may include:

* Temporary redness, swelling, or discomfort 

* Minor bleeding or bruising

* Risk of infection if post-care is not followed 

* Skin irritation or allergic reaction to topical products used

Alternative and expected outcomes have been discuseed with me.  I have had the opportunity to ask questions and have them answered to my satisfaction.

 

Patient Acknowledgement and Consent

By signing below, I Acknowledge that:

1. I understand that this treatment is being performed by a licensed esthetician, not a licensed health-care provider.

2. The service is being provided under the supervision of the licensed medical professional listed above.

3. I understand the nature, risks, benefits, and alternatives of microneedling.

4. I consent to receive this series of microneedling treatments as outlined above.

5. I know I can withdraw consent at any time.