Skin Needling Consent

Skin Needling Consent
I consent and authorise my practitioner to perform Skin Needling (Microneedling) on me. I understand the following points and have had the opportunity to ask any questions that may arise during my consultation.
In relation to Skin Needling treatments, I have been advised as follows:
1. Treatment is successful on most clients but individual results cannot be guaranteed.
2. Most clients require 3-6 treatments to achieve the desired results, some may require more. Individual results depend on many factors; thus it is diffiult to advise on exact number of treatments required.
3. Results might not be present until 3-6 months after having course recommendation and initial treatment.
4. Darker skin type clients will require additional treatments due to potential lower intensity application.
5. No UV exposure for 24-48 hours, the use of SPF 30+ or higher is mandatory.
6. Not following the program regarding timing of treatments and aftercare advice will reduce/affect efficacy of the treatment.
7. Prime your skin two weeks prior with AHA’s, vitamin A and vitamin C in the lead up to your treatment if possible and cease use of Retinol 12 hours before your scheduled treatment.
Even though the risk of complication is extremely low, the following can occur:
(Please read thoroughly and understand)
Risks associated with Skin Needling treatments:*

Pigment changes may occur (light or dark spots on the skin) lasting 1-6 months. Freckles may temporarily or permanently disappear in treated areas. Other potential risks include crusting, itching, pain, bruising, pimple-like bumps, dry skin, hypopigmentation (lightening of the skin), hyperpigmentation (darkening of the skin), blistering, burns, infection, scabbing, swelling, a very small risk of scarring and a failure to achieve the desired resultAllergic or delayed inflammatory reactions can developPrior to initiation of treatment, any suspicious pigmented lesions should be correctly identified by a physician to be benign. A medical certificate to this effect is requiredI understand the sensation of Skin Needling treatments is sometimes uncomfortable and feels like a prickly and mild sunburn sensation after treatmentI am aged 18 years or over (otherwise parent or guardian to sign)I will advise my practitioner of any changes that occur during my treatment that can increase potential risks or reduce efficacyI also understand there will be no refund for any performed services
In relation to my initial and subsequent treatments I advise that:*

I have not had unprotected sun exposure (including tanning beds and fake tan creams) in the last 2-4 weeksI have no history of seizures and I have disclosed all known allergies (eg. Latex, etc)I am not taking any medications causing photosensitvity (prescription/non-prescription) eg. St Johns Wort, Anti-coagulants, etc.I do not have a history of keloid & hypertrophic scar formationI do not have active infections/immunosuppressionI do not have Herpes I or II - in the areas to be treatedI have not used Tretinoin (Retin-A) within the last 2 weeksI have not had any Laser Resurfacing within the last 6 monthsI have not used Oral Isotretinoin/Accutane - within the last 6 monthsI have advised my clinician if I am diabeticI am not pregnant, breastfeeding and not taking any medication which may affect treatment outcomesI have received the Pre- and Post-care Information Sheet and agree to adhere to all of the recommendations within
Consent

I have read all of the above and have had taken the opportunity to have any questions satisfactorily answered before agreeing to undertake this treatment.

Note: Do not sign this form until you have read and understood all of the above.
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