MICRONEEDLING CONSENT FORM

I authorize Qskins Laser & Aesthetics to perform Micro-Needling treatments for me.

I understand that Micro-needling is a treatment where a fine needles will be introduced through the skin. This will combine active ingredients to go deeply into the dermis.

Description of the Procedure:

The E-Pen is an Epidermal Micro-Exfoliation (EME) device used to stimulate the tissue and improve the appearance of the skin. It is designed for use by skin care professionals. The procedure is performed in a safe and precise manner utilizing the Turbo Safety CartridgeTM, a sterile micro-exfoliation component. The procedure is typically completed in 30-60 minutes. The treatment time can vary based on the required treatment and anatomical site being treated.

Precautions & Warnings

1. Discontinue auto-immune therapies or retinoid (Retin-A) and/or any form of skin treatment 24 hours prior to procedure, under care and direction of a physician.
2. Not to be administered for 6 months after isotretinoin (Accutane) regime.
3. Patients with facial outbreaks such as herpes simplex virus, medication must be taken per doctor’s instructions.
4. Any metal allergies or skin allergies?
5. Subjects on any medications that would affect the characteristics of the skin should be stopped for two months prior to treatment under the care and direction of a physician.
6. Have you had a face lift or eyelid surgery within the past year, or dermabrasion, remodeling, deep chemical peels, or any surgical procedure on the treatment area within the previous 3 months.
7. Have you had Botox, collagen, fat, or other methods of augmentation with injected materials in the treatment area in previous 6 months.
8. Excessively tanned or sunburned skin from the sun, tanning beds, or tanning creams within previous 2 weeks.

Contraindications:

Treatment with this device is contra-indicated for patients with any of the following conditions:

• Keloid scars
• History of eczema, psoriasis and other chronic conditions
• History of actinic (solar) keratosis, diabetes, raised moles or warts on targeted area
• History of hemophilia, irregular blood pressure, tuberculosis, liver function issues
• Susceptibility to capillary ectasia due to steroid use for extended periods
• Scleroderma
• Collagen vascular disease
• Cardiac abnormalities, pacemaker, blood clotting problems
• Blood thinning medication
• Active bacterial or fungal infection
• Immunosuppression
• Facial melanosis
• Malignant tumors
• History of any type of cancer or suspicious lesions or moles in treatment area
• Pregnant or nursing women

I understand that I might experience the following side effects and will confirm that it is normal. I also understand that it will go back to normal within 24-48 hours.

• Flushed or red skin
• The tightness of the skin
• Mild sensitivity to touch
• Moderate sunburn
• Itching and burning

I confirm that I will follow the pre-care and post-care instructions by the specialist.

I understand that results will vary between individuals. I understand that although I may see a change after my first treatment; I may require a series of sessions to obtain my desired outcome.

The procedure contraindications, precautions and warnings have been explained to me including alternative methods; as have the advantages and disadvantages.

I am advised that though good results are expected, the possibility and nature of complications cannot be fully anticipated. Therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that the Micropen treatment is not permanent as natural degradation will occur over time.

I state that I have read (or it has been read to me) and I understand this consent and I understand the information contained in it.

I understand the risks and complications of this procedure and I still like to proceed with it. These are the following risks: infection, hyperpigmentation, allergic reaction, scarring, pain, itchiness, or swelling.

I understand that this procedure or service is non-refundable.

I release Qskins Laser & Aesthetics from any liabilities and hold harmless against damages or accidents that might happen during the procedure.

I confirm that I will consult my physician if I have the following contraindications:

• Rashes
• Acne
• Skin infection
• Viral, fungal, bacterial infection
• Pregnant
• Diabetes
• Taking NSAIDS, Warfarin, or any anticoagulants

I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner.