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Microneedling Consent Form

Please read carefully before you sign the waiver and consent to receive Microneedling treatment at Ease Medspa & Wellness Group. 

I hereby authorize Ease Medspa & Wellness Group to perform Microneedling Therapy (Collagen Induction Therapy) on me. I understand this technique involves the introduction of fine needles through the skin. 

 

The purpose is to create micro-channels in the skin allowing the infusion of active ingredients to penetrate deeply and effectively into the dermis, nourishing the skin and stimulating the regrowth of collagen, and a series of 4 to 6 treatments are recommended in order to achieve the best result.

I understand that I may expect:

• Depending on the area of your face or body being treated, the procedure is well-tolerated and in some cases virtually painless, feeling only a mild prickling sensation.

• I understand that the administration of numbing creams may be used if deemed needed.

• The skin will be pink or red in appearance, much like a sunburn, for a couple of hours following treatment.

• Minor bleeding and bruising is possible depending on the length of the needle used and the number of times it is pressed across the treatment area.

• The skin may feel warm, tight, and itchy for a short while. This should subside in 12-48 hours.

 

I understand that there are some possible side-effects:

Temporary bruising, skin discomfort during injections, redness or swelling, lightening or darkening of the skin, itching and burning. Skin infection is a possibility any time an injection or surgical procedure is done. If you have a history of cold sores, this procedure may cause flare ups. Side effects are most of the time temporary and typically resolve within 3-4 days. Total healing time depends on the depth of the treatment, skin type, and skin condition, and some clients may heal completely in 24 hours.

I understand the contraindications listed below, and I will notify my provider if any of the following apply to me:

 

  • Have used Accutane (isotretinoin) within the last year. 
  • Active skin infections, conditions - viral, fungal, bacterial, rashes, warts, skin cancer , herpes simplex in the area to be treated.  
  • Active acne 
  • Immune-suppressed patients 
  • Skin-related autoimmune disorders
  • Pregnant or breast-feeding  
  • On anticoagulants (NSAIDS, ASA, Coumadin/Warfarin)
  • Recent ablative dermal procedures
  • Rosacea 
  • Have any history of keloid, cold sores, hypertrophic scars or poor wound healing  
  • Diabetes

The benefits and risks of the procedure have been explained to me, and I accept these benefits and risks. 

 

By my signature, I certify that I have thoroughly read and understand the contents of this form and the disclosures listed above were made to me. I am also aware of and accept the risk of rare and unforeseen complications which may not have been discussed and which may result from this treatment. 

 

I acknowledge that no promises or guarantees have been made to me as a result of the treatment. I am aware that the results achieved by this treatment may vary from person to person. 

 

I have had the opportunity to ask questions and seek clarification of this procedure and its alternatives including no treatment and my questions have been answered satisfactorily. I hereby give my voluntarily consent to have this treatment performed on my skin by a licensed technician and to follow all post-treatment protocols.

 

Dated: January 26, 2021

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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