Microneedling.pdf 55.96 KB

Name:

Date of birth:

Address:

Phone number:

Email:


Please read this consent form thoroughly. 

Please answer all questions. 

If you have any uncertainty regarding questions, please discuss with your doctor. 


I __________________, hereby consent to undergo a mesotherapy/skin booster treatment by ___________________. I understand that Microneedling, also known as collagen induction therapy, is a minimally invasive procedure involving the use of fine needles to create hundreds of tiny, invisible puncture wounds in the top layer of the skin. This stimulates the body’s natural wound healing processes, resulting in increased collagen and elastin production.

Purpose of Treatment: Mesotherapy skin boosters aim to improve skin hydration, texture, and overall appearance.

Treatment Plan: - The procedure typically takes 30-60 minutes, depending on the size of the treatment area.

- A topical numbing cream may be applied to minimize discomfort.

- The microneedling device is passed over the skin, creating controlled micro-injuries.

- Post-treatment, serums or calming treatments may be applied to enhance results.


Please answer the following questions.

Yes

No

1. Do you currently have an infection in the area you would like to treat?

Y

N

2. Do you have known allergies or sensitivity to ingredients used in microneedling?

Y

N

3. Do you currently have open wound or cuts in the area you would like to treat?

Y

N

4. Do you have Diabetes?

Y

N

5. Are you on any treatment for your heart or high blood pressure?

Y

N

6. Are you currently pregnant or breastfeeding?

Y

N

7. Do you have a history of keloid scar formation?

Y

N

8. Do you have a history of poor wound healing?

Y

N

9. Do you have any autoimmune disease like Lupus?

Y

N

10. Are you currently using steroid containing medication?

Y

N

11. Are you currently using blood thinners including Aspirin?

Y

N

12. Do you have a history of skin cancer?

Y

N

13. Do you have psoriasis?

Y

N

14. Do you have kidney disease?

Y

N

15. Do you have liver disease?

Y

N

16. Are you a smoker?

Y

N

17. Do you currently have cold sores or shingles?

Y

N

18. Do you often get cold sores or shingles?

Y

N

 

Risks and Side Effects:

While microneedling is generally safe, potential risks and side effects include:

Y

N

              Redness, swelling, and discomfort in the treated area



             Bruising and pinpoint bleeding



              Allergic reactions (rare)



              Infection (very rare) at the treatment site

              Hyperpigmentation or hypopigmentation

              Temporary skin sensitivity

               Allergic reactions to topical numbing agents or post-care products 




Pre-Procedure

-Inform your healthcare provider of any medical conditions, including skin conditions such as eczema, rosacea, or psoriasis.

- Discuss any medications you are taking, including prescription and over-the-counter medicines, vitamins, and herbal supplements.

-Avoid sun exposure and tanning beds for at least 24 hours before the procedure.

- Avoid using retinoids and other potent skincare products for several days before the procedure.

Post-Treatment Care

- Follow the post-care instructions provided by your healthcare provider.

- Avoid sun exposure and use a broad-spectrum sunscreen with at least SPF 30.

- Avoid strenuous exercise, saunas, and steam rooms for 48 hours post-treatment.

- Avoid using makeup, retinoids, and other potent skincare products for a specified period as advised by your healthcare provider.

Alternative Treatments

 I acknowledge that alternative treatments or procedures may exist for achieving similar results and I have chosen mesotherapy skin boosters based on information provided to me.

Financial Responsibility

I understand that I am financially responsible for the microneedling treatment sessions as discussed with the clinic.

Patient Consent

I have read and understand the above information about microneedling. I have discussed the procedure with my healthcare provider and have had all my questions answered to my satisfaction. I understand the risks and benefits associated with microneedling and agree to proceed with the treatment.

By signing this form, I consent to receive microneedling treatment from Dr. BB Crook at Arcabee Aethetics.


Signature of Patient: ________________________
Date: _______________