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 Microneedle Consent

Description of the Procedure: The Microneedle Penskin needling system allows for controlled induction of the skin’s self-repair mechanism by creating micro “injuries” in the skin which triggers new collagen synthesis, yet does not pose a significant risk of permanent scarring. The result can yield smoother, firmer and younger looking skin. Skin needling procedures are performed in a safe and precise manner with the use of the sterile Microneedle Pen needle head. The procedure is normally completed within 30-60 minutes depending on the required treatment and anatomical site.

Potential Side Effects: After the procedure, the skin will be red and flushed in appearance in a similar way to moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on the treated area. Other potentials could be mild dryness causing peeling, or the opposite, mild purging of oils, causing a temporary increase in breakouts. Typically, these side effects should diminish greatly after within 24 – 72 hours. Typically, after 3 days there should be little to any evidence that the procedure has taken place. 

Patient Consent:I understand that results will vary between individuals. I understand that although I may see a change after my first treatment; I may require a series of treatment sessions to obtain my desired outcome. The procedure and side effects have been explained to me including alternative methods - as have the advantages and disadvantages. I am advised that although good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that the (enter name of your Microneedling Device here)treatment is not permanent, as natural degradation will occur over time. I have read (or it has been read to me) and I understand this consent and I understand the information contained in it. I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner.  

Contraindications:   

Keloid scars, history of eczema, Psoriasis and other chronic conditions, history of actinic (solar) keratosis, history of Herpes Simplex (cold sore) infections, history of diabetes, presence of raised moles, warts on desired treatment area.  


Absolute contraindications include:

scleroderma, collagen vascular disease, cardiac abnormalities,blood clotting disorders, active bacterial or fungal infection, active inflamed acne, immune suppression, Scars less than 6 months old, Chemo Radiation (within 6 months), Retin-A use with in 2 weeks, Accutane (within 6 months)  


Not recommended for women who are pregnant or nursing. 

  

Please Initial You Agree to the Following: 

No guarantee can be given to me as to the condition of my skin or degree of improvement expected following treatment. 

I understand the multiple treatments and the use of home care products are required to achieve optimal results. I understand that I must follow the home care regime specifically designed for me.

I understand it is best to avoid sun exposure 2 weeks before and after my treatment. If outdoors, I will apply a broad spectrum sunscreen with SPF-30, 30 minutes prior to sun exposure and reapply every 2 hours. 

I understand in rare cases, allergies or sensitivities have been reported to products used during treatments.

 I understand photos are required for my medical chart, will be used for medical reference and can be used as case study.

I understand that the following are contra-indications for Microneedling: 

  • Infected skin disorder; open cuts, wounds, abrasions  
  • Cardio vascular disease, must have doctors consent  
  • A pace maker is a direct contra-indication  
  • Highly anxious patient
  • Use of accutane or topical retinoids
  • Pregnancy  
  • Sunburned or irritated skin  
  • Untreated sinusitis – can cause pain in sinus area  
  • Numb areas without sensation 
  • Diabetes or impaired healing – consent from physician required  
  • Porphyria

 

 

I understand that I need to sleep on clean sheets or a towel the first 48 hours after treatment to avoid risk of any infection.

 

  

Most people heal without any problems. However, here are some problems that you may encounter: If you are prone to getting fever blisters (herpes simplex) then you might even develop a herpes infection. You will notice that the skin becomes thickened and has a different feel. In fact you should recognize the familiar symptoms of herpes. If so then apply a suitable anti herpetic preparation. Contact your primary physician for an anti-viral medication. 

You might notice small white dots appearing on the skin. These might be simple little retention cysts (Milia) or they could be minute infected areas. Carefully but firmly wipe them away and apply an antibiotic lotion. It is a good idea to consult your doctor about this. Do not allow the white dots to remain on the skin and if you are not able to remove them yourself then please consult with your doctor.  

If the skin becomes painful and redder, then you may have developed an infection and you must see your doctor at once.  

 

LIABILITY RELEASE:  I understand that results will vary between individuals.  I understand that although I may see a change after my first treatment, I may require a series of sessions to obtain my desired outcome. The procedure and side effects have been explained to me including alternative methods; as have the advantages and disadvantages.  I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment.  I am aware that this treatment is not permanent as natural degradation will occur over time.  I certify that the information I have given is accurate and complete to the best of my knowledge. I hereby release Lüz Lounge medical staff, partners and/or associates from any legal or financial responsibility. I state that I have read (or it has been read to me) and understand this consent and I understand the information contained in it. 


I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner.

 

April 21, 2024

I authorize Luz Aesthetics to take photos and/or video for sole purpose of education with marketing materials on our website, social media.  All photos and videos are kept in patients file with a HIPPA compliant database only accessible to Luz Aesthetics staff. I understand I not be reimbursed for usage. I understand and agree that these materials shall become the property of Luz Aesthetics’s and will not be returned. If you dont not consent to marketing use, use initials (XX), If you do consent to marketing use please type your initials. 

April 21, 2024

 

I understand I’m getting consulted and treated by Dr. Edmund Fisher’s (Santa Monica), Dr, Noam Rosines (Houston)Nurse Practitioners, Registered Nurses and Licensed Esthethicians today

April 21, 2024

 

STATE  MEDICAL SERVICES CONTRACT  

All Medical treatments are performed by Edmund Fisher MD and Noam Rosines MD Inc. Medical Group, dba Luz Lounge

A signed copy of this document is to be emailed/given to the client upon request. Original is to be filed in Client’s medical records. Arbitration Agreement CD0501Y8v2 

ARTICLE I: ARBITRATION Article 1.1: Agreement To Arbitrate: It is understood that any dispute as to medical malpractice by Client, including any party that would have standing to assert a claim on behalf of or in connection with services provided to Client, that is as to whether medical services rendered under this contract were unnecessary, unauthorized or lacking informed consent or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by State law, and not by a lawsuit or resort to court process except as State law provides for judicial review of arbitration proceedings. For purposes of this agreement, “Dispute” means any claim or controversy of whatever kind or nature including (without limitation) any claim or controversy regarding the formation, validity, interpretation and/or enforce ability of this agreement to arbitrate and any claim or controversy by the Client asserting loss of consortium, wrongful death, emotional distress or punitive damages. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.  Article 1.2: Procedure For Initiating Arbitration: Either party to this agreement may initiate Arbitration by submitting a Demand for Arbitration in writing to the other. The Demand shall contain a plain and simple statement of the nature of the Dispute and the remedy demanded. There shall be one Arbitrator who shall be a retired Judge of a court of record. The Arbitrator shall be selected by agreement of the parties on or before 30-calendar days of the date that the Demand for arbitration is deposited for delivery with a common carrier (as determined by a postmark or other equivalent writing imprinted by the common carrier). If the parties have not agreed to a selection of the Arbitrator, than either party may petition the appropriate Superior Court to appoint the Arbitrator and, consistent with CCP § 1281.6, the Superior Court shall appoint the Arbitrator, who shall have the qualifications stated in this paragraph.  Article 1.3: Law Governing Arbitration; Arbitrator’s Award And Enforcement. Without reference to its choice of law rules, the Arbitrator shall apply the substantive law. The Arbitrator shall render his or her award in writing and the award shall separately state the Arbitrator’s findings of fact and conclusions of law. The Arbitrator’s award shall be binding on the parties to the arbitration and judgment on the award may be entered by a court of competent jurisdiction. Judicial proceedings to confirm, amend, or vacate the arbitration award shall also take place. To the extent permitted by law, venue for such proceedings shall be in the county (or the federal judicial district) where the services were rendered. Unless the Arbitrator shall determine otherwise, the Arbitration shall take place in the county where the services were rendered. The Arbitrator shall have the authority to hear any claim and award any remedy that could otherwise be heard or rendered by the Superior Court or a federal district court. Discovery shall proceed in accordance with State Code of Civil Procedure, §§ 1283.1, 1282.05, and, in addition, any party, may, of right, bring a motion for summary judgment or adjudication in accordance with CCP § 437c. The parties to this agreement agree to arbitrate in one proceeding all claims arising out of the same or a related incident, transaction or occurrence. Article 1.4: Small Claims Court: Notwithstanding the foregoing any party to this agreement may initiate and prosecute in the small claims division of the Superior Court any claim at law demanding an amount equal to or less than the jurisdictional limit of the small claims division. Notwithstanding applicable law, no judgment in an action initiated in the small claims division may be entered for an amount in excess of the jurisdictional limit of the small claims division.  Article 1.5: Severability: If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO JURY OR COURT TRIAL. 

I have read and agree to the terms/conditions listed in this agreement and understand that I have the right to receive a copy of this arbitration agreement upon request.

 

April 21, 2024

 






Please select who is receiving the consult/treatment today
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First Client's Name

First Name*

Last Name*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information

Please list any medical history or skin disease history

Please list all medications taken.

Allergies to medications or ingredients? Please list
Sensitivity or tolerance to numbing cream or injectable lidocaine?*
No
Yes
Any history of keloid scarring?*
No
Yes
Any history of Scleroderma?*
No
Yes
I do not have any of the following: Scleroderma, collagen vascular disease, cardiac abnormalities, blood clotting disorders, active bacterial or fungal infection, immune suppression, Scars less than 6 months old, Chemo Radiation (within 6 months) Accutane (within 6 months)*
No, I do not have any of the above.
Yes, I do have one of the above.
I agree that I not currently pregnant or breastfeeding.*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding
I agree that microneedling takes 7 full days of downtime and that if I go out in the sun while healing, it can increase the risk of hyperpigmentation (brown spots)*
No
Yes
First Client's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Please list any medical history or skin disease history

Please list all medications taken.

Allergies to medications or ingredients? Please list
Sensitivity or tolerance to numbing cream or injectable lidocaine?*
No
Yes
Any history of keloid scarring?*
No
Yes
Any history of Scleroderma?*
No
Yes
I do not have any of the following: Scleroderma, collagen vascular disease, cardiac abnormalities, blood clotting disorders, active bacterial or fungal infection, immune suppression, Scars less than 6 months old, Chemo Radiation (within 6 months) Accutane (within 6 months)*
No, I do not have any of the above.
Yes, I do have one of the above.
I agree that I not currently pregnant or breastfeeding.*
No, I am not pregnant or breastfeeding.
Yes, I am pregnant or breastfeeding
I agree that microneedling takes 7 full days of downtime and that if I go out in the sun while healing, it can increase the risk of hyperpigmentation (brown spots)*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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