Aeris Medical Microneedling Pre/Post Care Consent Form

Microneedling Pre/Post Care Consent Form
Aeris Medical Aesthetics — Microneedling Therapy Consent + Pre/Post Care
1) Authorization + Acknowledgment
I hereby authorize Aeris Medical Aesthetics (“Aeris”) to perform Microneedling Therapy on me. I understand that this procedure is elective/cosmetic.

I certify that I have disclosed my relevant medical history, medications, supplements, allergies, and any prior cosmetic procedures to my provider. I understand that it is my responsibility to update Aeris regarding any changes before each treatment.

2) What to Expect
I understand the following regarding Microneedling Therapy:

Depending on the treatment area and device settings (including needle length/depth), the procedure is generally well tolerated. Sensations may include a mild to moderate prickling, scratching, or pressure.
A topical anesthetic may be applied prior to treatment to reduce discomfort, when appropriate.
My skin may appear pink/red (similar to a sunburn) for several hours and possibly up to several days following treatment.
Minor bleeding, pinpoint bleeding, and/or bruising may occur depending on needle depth, passes, and treatment area.
My skin may feel warm, tight, dry, or itchy temporarily. These effects typically subside within 12–48 hours, but may last longer for some individuals.

3) Possible Side Effects / Risks
I understand that side effects and risks are generally minimal, but may include:

Temporary redness, swelling, dryness, flaking, sensitivity, and/or mild discomfort
Scab formation (rare), irritation, or prolonged redness
Milia (small white bumps) may form and can be treated/removed by a provider if needed
Post-inflammatory hyperpigmentation (PIH) (darkening of the skin) can occur, especially in deeper skin tones; it is uncommon and often resolves, but may persist
If I have a history of cold sores (HSV), microneedling may trigger a flare-up
Temporary “sunburn-like” effects may last up to 4 days
Freckles may temporarily lighten or permanently fade in treated areas
Other potential risks include: crusting, itching, bruising, infection, swelling, acne flare, allergic reaction to topical products, and failure to achieve desired results
Permanent scarring is rare (reported as less than 1%), but is possible
I understand that results are not guaranteed and vary by individual.

4) No Guarantee / Ongoing Treatment
The benefits and risks of Microneedling Therapy have been explained to me. I accept these benefits and risks. I understand that outcomes vary and there is no guarantee of a specific result. I understand that multiple sessions and/or ongoing maintenance treatments may be needed.

I acknowledge that I am aware of and accept the risk of rare and unforeseen complications that may occur even when the procedure is performed properly.

5) Alternatives
I have had the opportunity to ask questions and seek clarification regarding this procedure and alternatives, including no treatment. My questions have been answered to my satisfaction.

6) Contraindications / When to Notify Provider
I understand the contraindications listed below and agree to notify my provider if any apply to me now or in the future:

Active infection (viral, fungal, or bacterial), including cold sores outbreak
Rashes, warts, suspicious lesions, or skin cancer in the treatment area
Active inflammatory acne in the treatment area
Immunosuppression or immune-suppressed conditions/medications
Skin-related autoimmune disorders
Pregnant or breastfeeding
Use of anticoagulants/blood thinners (including certain NSAIDs/ASA, warfarin/Coumadin) or bleeding disorders
Recent ablative dermal procedures/laser resurfacing or deep chemical peel
Uncontrolled rosacea or severe sensitivity in the area (as determined by provider)
Diabetes that is uncontrolled or healing disorders
Actinic (solar) keratosis in the treatment area
History of keloids or abnormal scarring

PRE-CARE INSTRUCTIONS (Before Your Appointment)
I agree to follow these guidelines unless my provider instructs otherwise:

Avoid sun exposure and tanning (including self-tanner) for 1–2 weeks prior; arrive without sunburn.
Avoid retinoids/retinol, tretinoin, adapalene, benzoyl peroxide, AHAs/BHAs, and exfoliants for 3–7 days before treatment.
Avoid waxing/threading/depilatories, harsh scrubs, or aggressive exfoliation in the area for 7 days prior.
Tell your provider if you have a history of HSV/cold sores; antiviral prophylaxis may be recommended.
Arrive with clean skin (no makeup, lotion, or sunscreen on the treatment area if possible).
Inform your provider of any recent illness, new medications, antibiotics, steroids, or changes in health status.
Discuss blood-thinning meds/supplements with your provider before treatment.

POST-CARE INSTRUCTIONS (After Treatment)
I understand and agree to the following post-care:

First 24 hours

Do not touch the treated area with unwashed hands.
Avoid makeup for 24 hours (or as directed).
Use only gentle cleanser and bland moisturizer as instructed.
Avoid heat exposure: strenuous exercise, hot showers, saunas, steam rooms, hot tubs.
First 3–7 days

Avoid retinoids/retinol, acids (AHA/BHA), exfoliants, benzoyl peroxide, harsh actives, and scrubs until fully healed.
Avoid swimming pools, lakes, and ocean exposure until skin is fully healed.
Do not pick, peel, or scratch flaking skin.
Sun protection

Use broad-spectrum SPF 30+ daily once approved by your provider and avoid direct sun exposure. Sun exposure increases the risk of hyperpigmentation, especially in deeper skin tones.
Expected downtime

Redness, dryness, tightness, mild swelling, and flaking are normal and temporary.
When to contact Aeris

Increasing pain, spreading redness, warmth, pus, fever, significant swelling, blistering, or any concerning symptoms.

7) Consent
By signing below, I confirm that:

I have read and understood this consent and the pre/post-care instructions.
I have had the opportunity to ask questions and they were answered.
I consent to Microneedling Therapy at Aeris Medical Aesthetics.
Patient Name *

First NameLast Name
Date

MonthDayYear
Date
Patient Signature *
I understand that although good results are expected, there cannot be any guarantee or warranty, expressed or implied, that I will be completely satisfied by the outcome or that I will not require additional treatment and/or ongoing treatment to achieve the result I seek. I understand that treatments will not cure any medical conditions nor provide immunity against re-occurrence of such conditions. The treatments are temporary and vary per patient with some patients experiencing shorter or longer effects. The number of treatments needed varies per patient and may be affected by the following factors including but not limited to: degree of skin irregularity; severity of volume loss; patient age; personal medical profile; basic metabolic rate; previous cosmetic procedures; history of trauma to the treated area; individual lifestyle choices; and individual patient preference.I understand that all product and service sales are final. No refunds on services or products. I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I agree to the terms of this agreement.I understand and voluntarily accept the risks associated with all the services provided at Aeris Medical Aesthetics, including but not limited to: waxing, facials, tanning, injections, laser services, and skincare products, etc., or the use of any of the location’s facilities. Except where prohibited by law, I acknowledge and voluntarily assume the risk of injury, accident, or death which may arise from the use of any skincare products or services performed by Aeris Medical Aesthetics. I agree Aeris Medical Aesthetics will not be liable for death or any injury, including, without limitation, personal, bodily, or mental injury, economic loss, or damage to me resulting from negligence, other acts of Aeris Medical Aesthetics, anyone acting on Aeris Medical Aesthetics’ behalf, or anyone using the services or facilities of Aeris Medical Aesthetics, to the fullest extent permitted by law.This agreement, together with Aeris Medical Aesthetics’ post-care plan rules and regulations, constitutes the entire agreement between you and us and cannot be amended except in writing signed by both parties. I and/or any of my heirs, executors, representatives, or assignees hereby release Aeris Medical Aesthetics from all claims or liabilities for death, personal injury, or property loss or damages of any kind sustained while on the premises. I agree that this form and waiver is in effect for all services offered by Aeris Medical Aesthetics, and will not expire unless specifically revoked or modified in writing by either party.I understand that Aeris Medical Aesthetics is intended to be a tranquil and professional environment and that any inappropriate behavior may result in termination of my services and full payment is expected. I also understand that any medical device used by the patient outside of Aeris Medical Aesthetics’ care, or failing to list or mention such medical devices, could result in unexpected or unwanted results.By signing this form, I agree to the above terms and release Aeris Medical Aesthetics and its employees from any liability.

I understand and agree.
If you have any questions or concerns, please contact Aeris Medical Aesthetics or your designated medical provider using the directory information below:

Amanda Armijo- Amanda@aerismedical.info

Lawrence Armijo- Lawrence@Aerismedical.info
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