I understand that as part of my healthcare, the healthcare providers of 4 You LLC. originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals. 4 You LLC. Notice of Privacy Practices provides specific information and complete description of how my personal information may be used and disclosed. I understand that a copy of the Notice of Privacy Practices is available at the front desk and understand that I have the right to review the notice prior to signing this consent. I understand that 4 You LLC. reserves the right to change the Notice of Privacy Practices. Prior to implementation of the revised Notice of Privacy Practices, there vised Notice will be mailed to me if I provide my address below. I understand I have the right to restrict the use and/or disclosure of my personal health information for treatment, payment, or healthcare operations and that 4 You LLC. is not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that 4 You LLC. has already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing. We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen. You can request a paper copy of this notice, or any revised notice, at any time (even if you have allowed us to communicate with you electronically). For more information about this notice or our privacy practices and policies, please contact the person listed at the end of this document.

NOTE: 4 You LLC. must obtain your written authorization to use your Private Health Information for any purpose other than treatment or billing. If you want 4 You LLC. to have access to disclose your Private Health Information to your spouse or any other person during your treatment, please sign below.

This information is for use by the parties named above only, and may not be disclosed to any other individual or agency without the patient’s consent or as otherwise provided by law. This authorization is subject to revocation at any time except to the extent the 4You, LLC has already taken action in reliance on it.

I understand that the information in my medical records may include information related to sexually transmitted disease, AIDS/HIV testing or diagnosis, mental health services, or drug/alcohol abuse diagnosis or treatment, and/or AIDS (Acquired Immunodeficiency Syndrome). Information in the form of audio, photo, or video has been designated above, if applicable.

I understand that 4 You, LLC, Ashley Caldwell, Certified Nurse Practitioner with NPI: 790336741, will not withhold health care if I do not sign this consent, but that exchange of private information with an outside entity such as a future employer or consulting physician will not be made without my consent. A copy of this consent and annotation concerning the persons or agencies with which information was exchanged will be included in my medical records. I understand that health information exchanged under this consent might be redisclosed by a recipient and no longer be protected by privacy laws.

Cosmetic Surgical is a unique practice and is considered a form of alternative medicine. Even though the physicians and nurses are board certified as medical doctors, nurses, nurse practitioners and/or physician assistants. Most health insurance companies exclude coverage for cosmetic surgical operations, or any resulting complications Please carefully review your health insurance subscriber-information pamphlet. Most insurance plans exclude coverage for secondary or revisionary procedure due to complications of cosmetic procedure.

Insurance companies are not obligated to pay for our services (consultations, insertions or pellets, or any other work done through our facility). We require payment at time of service. WE WILL NOT, however, communicate in any way with insurance companies.

This form and your receipt are your responsibility and serve as evidence of your treatment. We will not call, write, pre-certify, appeal nor make any contact with your insurance company. If we receive a check from your insurance company, we will not cash it but will return it to the sender. Likewise, we will not mail it to you. We will not respond to any letters or calls from your insurance company.

The fees charged for this procedure do not include any potential future costs for additional procedures that you elect to have or require in order to revise, optimize, or complete your outcome. Additional costs may occur should complications develop from the injections and will also be your responsibility. In signing the consent for procedure, you acknowledge that you have been informed about its risks and consequences and accept responsibility for the clinical decisions that were made along with the financial costs of all future treatments.

I here by authorize the healthcare providers at 4You LLC to perform the microneedling procedure using the Exceed microneedling device. I understand that the treatment is used for fine lines and winkles, and can improve the appearance of acne scaring as well. The procedure involves creating tiny microscopic punctures in the epidermal and dermal layers of the skin using sterile stainless steel needles which can stimulate neocolla génesis.  I understand this is not to prevent facial wrinkles although it can be helpful.  It is important to understand that results may vary.  This device is very successful with most patients, but there are no guarantees. This procedure opens the channels in your face to allow the products being applied to actually penetrate to the desired layer of skin which will greatly enhance the effectiveness of the products you are using.  The recommendation is a minimum of 3 treatments spaced 30 days apart and should be done quarterly for maintenance. Results may vary based on skin type, medical conditions, and compliance with pre and post treatment instructions. I understand all the information discussed above and wish to proceed with the microneedling treatment. 

Alternative forms of treatment include undergoing the proposed medical micro needling treatment.  Other forms of skin treatments such as chemical peels, laser and /or light based treatments, surgical procedures, dermabrasion, or resurfacing may be substituted.  In certain situation, treatment with exceed micro needling device may offer a specific therapeutic advantage over other forms of treatment that involve skin resurfacing or surgical procedures. 

I am aware of the following possible experiences, side effects and risks:

Pain and discomfort: The level of pain and discomfort varies with person tolerance , and both may be experienced  during treatment with gradual cessation of pain after treatment.  In a clinical study studies the Exceed microneedling device, subjects reported that they experienced minimal pain in most areas to moderate pain in other more sensitive areas such as around the mouth.

Redness and swelling: Short term redness (erythema) or swelling (edema) of the treated are is common and may occur.  An urticarial (hive like) reaction may occur as well.  In the clinical study using the Exceed micro needling device, subjects experienced a non-persistent inflammatory response, erythema, and edema in the first one to six days after treatment.  Most patient will have redness (erythema) and tightness to skin for the first 48 hours.

Pinpoint bleeding: Localized pinpoint bleeding in the treatment areas are expected and the goal of a successful treatment.  Pinpoint bleeding should not persist greater than 24 hours.  Please notify your provider if you have this problem.  Not taking NSAIDs and fish oil 48 hours prior to treatment is recommended to reduce prolonged bleeding.

Skin Sensitivity and Irritation: Itching, tenderness, warming (feeling similar to a sunburn), exaggerated responses such as hot or cold temperatures may occur briefly.  This typically resolves during the healing process, which should clear after 8 days. In rare situation it may be chronic.

Infection: Infection is a possibility whenever the skin surface is disrupted, though proper wound care should prevent this.  Individuals predisposed to herpes simplex labials (HSL) are at increased risk for developing the formation of blister caused by HSL.  Prophylactic antiviral is recommended for patients with history of HSL. Herpes simplex virus infections (cold sores) around the mouth can occur /reoccur following treatment.  This applies to both individuals with a history of herpes simplex virus infection and individual with no known history of herpes simplex virus infection in the mouth area.  Please discuss with your provider.  If signs of infection develop, such as pain, heat or surrounding redness, please contact our office at (614) 300-7988. 

Medications: Please inform your provider of any and all medications currently being taken.

Pigment changes: There is a possibility that the treated area ca become either hypopigmented (lighter or white) or hyperpigmented (darker) in color compared to the surrounding area of the skin. This is usually temporary but can be permanent.  The Exceed micro needling device has not been studied in the patients with FST IV-VI.

ACCUTANE (Isotretinoin)- Accutane is a prescription medication used to treat certain skin diseases. If you have ever taken Accutane, you should discuss this with your treatment provider. This drug may impair the ability of skin to heal following treatments for a variable amount of time even after the patient has ceased taking it. Individuals who have taken this drug are advised to allow their skin adequate time to recover from Accutane before undergoing skin treatment procedures.

EPIDERMAL CRUSTING- During the healing phase, small pinpoint crusts, flaking, or peeling may appear in place of each microscopic puncture. It is important not to pick or disturb the crusts as they heal. They may require medical attention if sensitivity or redness occurs. Crusts will typically slough off in 1-3 weeks after treatment.

PUSTULES & MILIA Formation of small pustules and milia within the first days after treatment may occur.

VISIBLE SKIN PATTERNS- the Exceed micro needling device may produce visible patterns within the skin. The occurrence of this is not predictable.

DAMAGED SKIN- Skin that has been previously treated with chemical peels or dermabrasion, or damaged by burns, electrolysis (hair removal treatments), or radiation therapy may heal abnormally or slowly following treatment by micro needling. The occurrence of this is not predictable.

Additional treatment may be necessary. If you have ever had such treatments, you should inform your treatment provider.

SCARRING- Scarring is a rare occurrence, but it is a possibility whenever the skin surface is disrupted. To minimize the chances of scarring, it is

IMPORTANT that you follow all post-treatment instructions carefully.

TEXTURAL CHANGES/CUTANEOUS INDENTATIONS- Textural and/or skin changes may occur because of treatment.

ALLERGIC REACTIONS- In some cases, local allergies to products used during or after treatment such as adhesive, numbing agents, topical preparations and topical post-care have been reported. Systemic reactions which are more serious may occur to drugs used during the procedure.

Allergic reactions may require additional treatment.

SUN EXPOSURE/ TANNING BEDS/ ARTIFICIAL TANNING- May increase risk of side effects and adverse events. It has been advised that you discontinue and avoid UV exposure and artificial tanning before, during, and after your treatment and recommended that you discontinue this

practice all together as the effects of the sun are damaging to the skin. A broad spectrum (UVA/UVB) sunscreen should be used to prevent further pigmentation. Exposing the treated areas to sun may result in increased scarring, color changes, and poor healing. Patients who tan, either outdoors or in a salon, should inform their treatment provider and either delay their treatment or avoid UV exposure until your provider says it is safe to resume. The damaging effects of UV exposure occurs even with the use of sunscreen or clothing coverage.

TREATMENTS- The number of treatments vary but multiple treatments are always required. The number of treatments needed to improve and reduce your facial wrinkling and/or facial acne scars is unknown.

LACK OF PERMANENT RESULTS- the Exceed micro needling treatment or other skin treatments may not completely improve or prevent future facial skin disorders, lesions, wrinkles, and/or acne scarring. No technique can reverse the signs of skin aging. Additional treatments with the Exceed micro needling device may be necessary to further improve facial wrinkling and/or facial acne scars. You may be required to continue with additional skin care maintenance programs. You may be disappointed with the results of an Exceed micro needling treatment.

OTHER RARE RISKS- Persistent inflammatory response, hematoma, erythema and edema lasting longer than 5 days. Fever within first 3 days after treatment, and headache within first two days after treatment.

UNKNOWN RISKS- There is the possibility that additional risk factors of Exceed micro needling treatment may be discovered.

TRAVEL PLANS- Any treatment holds the risk of complications that may delay healing and delay your return to normal life. Please let the treatment provider know of any travel plans, important commitments already scheduled or planned, or time demands that are important to you, so that appropriate timing of your treatment can occur. There are no guarantees that you will be able to resume all activities in the desired time frame.

SKIN CANCER/SKIN DISORDERS- Treatment with the Exceed micro needling device does not offer protection against developing skin cancer or skin disorders in the future.

BODY PIERCINGS- Individuals who currently wear body-piercing jewelry in the treated region are advised that an infection could develop from this treatment.

MENTAL HEALTH DISORDERS AND ELECTIVE PROCEDURES- It is important that all patients seeking to undergo elective treatments have realistic expectations that focus on improvement rather than perfection. Complications or less than satisfactory results are sometimes unavoidable, may require additional treatments, and can be stressful. Please openly discuss with your treatment provider, prior to the treatment, any history that you may have of significant emotional depression or mental health disorders. Although many individuals may benefit psychologically from the results ofelective procedures, effects on mental health cannot be accurately predicted.

PATIENT COMPLIANCE- Follow all pre-and post-instructions carefully; this is essential for the success of your outcome. Post-treatment instructions concerning appropriate restriction of activity, use of post-treatment care and use of sun protection must be followed to avoid potential complications, increased pain, and unsatisfactory results. Your treatment provider may recommend that you utilize a long-term skin care and/or post care program to enhance healing and results following a treatment with the Exceed microneedling device.

Informed consent documents are used to communicate information about the proposed surgical treatment of a disease or condition along with disclosure or risks and alternative forms of treatment(s). The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered. Your treatment provider may provide you with additional or different information, which is based on all the facts in your particular case and the state of medical and device knowledge. Informed consent documents are not intended to define or serve as the standard of care. Standards of care are determined based on all facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.

The following points have been discussed with me:

• The potential benefits and limitations of the proposed procedure, including the possibility that the procedure may not work for me.
• The possible alternative treatments include topical medications or skin care, chemical peels, other laser or light therapies, or no treatment at all.
• The probability of success.
• The reasonably anticipated consequences if the procedure is not performed.
• The most likely possible complications/risks involved with the proposed procedure.
• Post treatment instructions.
• Short term effects may include reddening, mild burning, temporary bruising or blistering. Hyperpigmentation and hypopigmentation have also been noted after treatment. These conditions usually resolve within 3-6 months, but permanent color change is a rare risk. 
• Avoiding sun exposure before, during, and after treatment reduces risk of color change.