Microneedling Consent Form

Microneedling Consent Form
Patient Name*

First NameLast Name
Age
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you used Accutane in the past year?

YesNo
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma?

YesNo
Have you had chemotherapy in the past 6 months?

YesNo
Do you have any of the following conditions:

PsoriasisEczemaDermatitisPregnancy and/or breastfeedingAutoimmune diseaseDiabetes _Herpes SimplexHeart disease and/or heart defectsHemophiliaCollagen Vascular DiseaseActive acne
Do you have any allergies? If yes, please list them below:
Are you currently taking any medications? If yes, please list them below:
Please read and initial where indicated. Micro-needling devices intentionally create very superficial “micro-injuries” to the outermost layer of the skin, inducing the healing process including new collagen production. Micro-needling has been shown to reduce the visibility of acne scars, fine lines, and wrinkles, diminish hyperpigmentation, and improve skin tone and texture, resulting in smoother, firmer, younger-looking skin. Skin needling treatments are performed in a safe and precise manner with the sterile devices and are normally completed within 30-60 minutes, depending on the selected area.*

Although, the majority of patients do not experience any complications with micro-needling, it is important you understand that risks do exist. The micro-needling procedure is minimally invasive, utilizing a set of micro-needles to inflict multiple, tiny, puncture/lacerations to the outermost layer of the skin. Because micro-needling penetrates the skin, it inherently carries health risks, including but not limited to those listed below. You should discuss any and all health concerns with your esthetician or attending healthcare provider PRIOR to signing this consent form.I understand that micro-needling may cause infection, pigment/color change, scarring, pain, persistent redness, itching, and/or swelling, and/or an allergic reaction.I understand that after the procedure, the skin will be red, with mild swelling and/or bruising, and might feel tight and sensitive to the touch. Although these symptoms may take 2-3 days to resolve completely, they will diminish significantly within a few hours after treatment.I understand there are certain contraindications that would preclude me from receiving micro-needling treatments including active acne, active infection of any type (bacterial, viral, or fungal), cardiac disease/abnormalities, collagen vascular disease, eczema, psoriasis, or dermatitis, hemophilia/bleeding disorders, keloid/hypertrophic scaring, pregnancy/lactation, raised lesions (moles, warts, etc.), skin cancer, sunburn, tattoos, telangiectasia/erythema, uncontrolled diabetes, vascular lesions (hemangiomas), rosacea, and sclerodermaunderstand that the use of Botox®, Juvederm®, Restylane®, and any other injectable must be disclosed prior to treatment.I understand that there are some contraindicated medications: blood thinner medications, chemotherapy or radiation, hormone replacement therapy, recent use of some topical medication.I understand that micro-needling is contraindicated within 72 hours of waxing, and within 1-3 weeks of a chemical peel.I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.I understand that it is imperative to my health that I disclose all of the information requested in the Client Profile/Health History.I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.I understand that I MUST avoid sun exposure for 1 to 2 weeks after a micro-needling treatment. I should also wear a daily SPF.I consent to “before and after” photographs for the purpose of documentation, potential advertising, and promotional purposes.
I understand that if I have any concerns, I will address these with my skin care specialist. I give permission to my skin care specialist to perform the micro-needling procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may
have additional questions or concerns regarding my treatment, I will consult the skin care specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the skin care specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.
ARBITRATION AGREEMENT
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process, except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Further, the parties will not have the right to participate as a member of any class of claimants, and there shall be no authority for any dispute to be decided on a class action basis. An arbitration can only decide a dispute between the parties and may not consolidate or join the claims of other persons who
have similar claims.
Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, as to whether this agreement is unconscionable, and any procedural disputes, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the healthcare provider, including any heirs or past, present or future
spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the healthcare provider and/or other licensed healthcare providers, preceptors, or interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the healthcare provider, including those working at the healthcare provider’s clinic or office or any other clinic or office whether signatories to this form or not.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the healthcare provider, and/or the healthcare provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages. This agreement is intended to create an open book account unless and until revoked.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) and provide National Arbitration and Mediation (“NAM”) with the party arbitrator’s contact information within thirty days of the date Respondent files its initial responsive pleading. A third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties from a list of arbitrators supplied by National Arbitration and Mediation (“NAM”) within thirty days thereafter. The list
supplied by NAM shall be a list of between 5 and 10 arbitrators, depending upon availability. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party’s equal share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that, where not in conflict with this agreement, the Healthcare Malpractice Dispute Resolution Rules and Procedures of NAM shall govern any arbitration conducted pursuant to this Arbitration Agreement. A copy of NAM rules are available on its website at
https://www.namadr.com or by calling 1-800-358-2550 to request a copy of the rules.
Article 4: General Provision: All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the healthcare provider within 30 days of signature and, if not revoked, will govern all professional services received by the patient and all other disputes between the parties.
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency
treatment), patient should initial here. _______. Effective as of the date of first professional services.
If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE
DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE
ARTICLE 1 OF THIS CONTRACT.
Both parties agree that this agreement may be electronically signed, and that the electronic signatures appearing on this agreement are
the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
CANCELATION POLICY:

• Cancelations within a 24-hour notice of the service, client will be charged 50% of the service scheduled.

• Please, if client has any symptoms of coughing, sore throat, extreme runny nose, or fever, client MUST cancel 24 hours before client's appointment. If client does not give 24-hour notice of cancellation with any of these symptoms, client will be charged 100% of the service and reported as a "no show". If symptoms start after the 24-hour policy, please text LLB immediately and we will reschedule the appointment.

• Clients that are more then 15min late will be charged the cancelation fee (50%) and asked to reschedule for quality of service.

•ANY NO-SHOW clients will be charged 100% cost of service scheduled.

• Second time "NO CALL NO SHOW" will no longer be able to book with LBB.
Name*

Provider Name
Date Signed*

MonthDayYear
Date
Signature of the patient*

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