Microneedling consent form

Microneedling Consent Form

Youthful Reflections, LLC 3 Geyser St., Suite 7 Ennis, MT 59729 (406) 925-3036 rnjordanstone@youthfulreflectionsmt.com
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Email
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Birthday
Emergency Contact

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Relationship to Patient
I am NOT currently pregnant or nursing.

I agree
Microneedling may NOT be used directly on and may be contraindicated for any of the below conditions. SELECT any of the health concerns below that apply to you.

Open Sores or lesionsUntreated skin cancerAny stage of melanomaBroken or irritated skin, Including such conditions as hives or dermatitis rosaceaEczema active cold soarsActive acneAny type of skin infectionsDiabetesAuto-immune disordersI DO NOT HAVE ANY OF THE ABOVE CONDITIONS
After treatment, I understand that most patients look as though they have a moderate to severe sunburn and the skin may feel warm and tighter than usual. It is also normal for the skin to feel tender to touch. At times, patients will experience some swelling in the area treated. Moderate skin flaking after day 3 is normal as well. Most patients recover within 24-48 hours. Because this device penetrates the skin, a risk of infection does exist. If this were to occur, please contact the office.

I UNDERSTAND
Current medications, supplements, topical lotions, creams, and ointments.
Allergies to medications, foods, chemicals, or metals
I understand that the microneedling procedure is moderately uncomfortable and a topical numbing cream will be applied to the area to be treated. This will greatly minimize the discomfort, however, it cannot be guaranteed that the procedure will be pain free.

I UNDERSTAND
I am not allergic to benzocaine, lidocaine, tetracaine. or other anesthetics?
I am NOT allergic to benzocaine, lidocaine, tetracaine. or other anesthetics?

I AGREE
I understand that I must wait at least 2 weeks after Botox and at least 28 days after Fillers to have a micro-needling treatment. Treatment prior to these time frames could result in unwanted distribution of Botox and inflammatory reactions at the injection sites of the Fillers. I also understand that if I have had a moderate facial peel, I must wait 14 days for treatment. And likewise, if I have had a deep facial peel, I must wait 28 days.

I UNDERSTAND
I have disclosed and affirmed that I discontinued any Retin-A products, Vitamin A products, and/or topical acne medications at least 3 days prior to treatment. If applicable, I affirm that I discontinued Accutane a minimum of 6 months ago. Failure to do so could result in significantly more severe, pronounced, and unwanted side effects.

I AGREE
I understand that the treatment of scars, whether accidental or surgical, is NOT indicated if the scar is less than 6 months old. To the best of my knowledge, I agree that I have disclosed an accurate time of its occurrence.

I UNDERSTANDHow old is the scar being treated? Answer below (under "other").Other
I have disclosed any bleeding or clotting disorders or current treatment with blood thinners, anti-platelet drugs and/or anticoagulants (other than aspirin, I understand that my treatment may be refused based on a specific review of the situation.

I UNDERSTAND AND AGREE
I have been advised that a series of 4 treatments, 4-6 weeks apart is the recommended number of treatments needed to achieve maximum benefits from microneedling. I understand that at times, scar tissue and/or stretch marks may benefit from additional treatments. I also understand that I cannot expect to see the same results with one treatment that I would see with a series of 4 treatments.

I UNDERSTAND
I understand the above instructed maintenance regime following my microneedling treatment. I understand that results of the treatment may continue to be seen 6-8 months after the last treatment. (This statement is based on the assumption of a series of treatments. After this time frame, changes usually begin to plateau.)

I UNDERSTAND
I grant Youthful Reflections, LLC, its representatives, and employees the right to take photographs or videos of me in connection with receiving any treatments from Youthful Reflections. I authorize Youthful Reflections, its assignees, and transferees to copyright, use, and publish the same in print or electronically. I agree that Youthful Reflections may use such photographs or videos of me with or without my name and for any lawful purpose, including for example such purposed as publicly, illustration, advertising, social media and web content.

I AGREEI do NOT agree
By my signature below,

I confirm that I have read and answered all questions to the best of my knowledge and understand that withholding necessary information about my health and medication may increase my risk of possible side effects.

I confirm that I have had the opportunity to ask any questions concerning the information the above. My questions and concerns have been specifically discussed, answered, and made clear to me.

By signing below, I AM SATISFIED WITH THE EXPLAINATION and I hereby give my voluntary consent to this procedure and release Jordan Stone, RN BSN and her business staff from liability associated with the procedure.
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Microneedling Consent Form