Hair Restoration Consent

I understand possible side effects include and are not limited to: slight or extreme redness, histamine reaction, swelling, stinging, itchy, tender, dry or flaking skin. In rare instances, hyperpigmentation/hypopigmentation, scarring, or infection can occur. I UNDERSTAND THAT I SHOULD ONLY APPLY PRODUCTS RECOMMEDED BY MY CLINICIAN POST TREATMENT.

I have avoided the following products/procedures THREE DAYS prior to treatment:

• Topical prescriptions including but not limited to Retin-A, Tretinoin, Differin, Tazorac

• Abrasive scrubs or other exfoliating products

I have not had any injections at the site of procedure where to have Micro-needling done within the last TWO WEEKS

Notify your technician PRIOR TO SIGNING THIS CONSENT if any of the following apply to you:

• Cold sores(or history), warts, open skin lesions, sunburn, extreme sensitivity, dermatitis, rosacea

• Blood thinning medications

• Accutane or generic within the past year

• Pregnant or breastfeeding

• Received chemotherapy or radiation therapy

• Collagen Vascular Disease

• Eczema, Psoriasis, or Dermatitis

• Hemophilia / bleeding disorders

• Keloid/hypertrophic scaring

• History of autoimmune disease or any condition that may weaken you immune system

Scalp Treatment

- If any, Apply the aftercare soothing gel/spray provided every 4 to 6 hours until it runs

out (3 to 5 days).

- Recommended: Keep scalp hydrated with stem cell serum (Relax3).

- Mild irritation, itching, redness and swelling may occur. Condition should improve

within 2 to 3 days.

- If any, Mild bumps/growth may form, should subside within 1 to 2 weeks.

- If any, all scabs should fall off within 1 to 2 weeks.

- If any, mild headaches and loss of sleep may occur due to increase in blood circulation.

*AVOID*

- Avoid water to the treated area for 24 hours.

- Avoid sun tanning for 7 days.

- Avoid sauna and any physical activities that produce perspiration for 2 -3 days.

- Please do not rub or pick the treated area for 5 -7 days.

- Avoid applying any products containing acid, exfoliation and peels.

- Avoid any/all hair treatments for 4 - 7 days.

I am undergoing treatment of my own free will. I agree that this procedure is being performed for cosmetic reasons and that no guarantee can be made as to the exact results of this procedure. I understand that every precaution will be taken to prevent complications and that complications from this procedure are rare, they can and sometimes do occur.

Although the results are usually dramatic, I have been informed that the practice of medicine is not an exact science and that no guarantees can be or have been made concerning the expected results in my case. Multiple treatments may be necessary to achieve optimal results.

ACKNOWLEDGMENT

 

BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS MICRONEEDLING CONSENT FORM AND THAT THE DISCLOSURES REFERRED TO HEREIN WERE MADE TO ME.