This consent form is designed to give you the information you need to make an informed decision about whether or not to undergo micro-needling for the purpose of skin surface improvement. If you have any questions, please call our office. Please initial all paragraphs. Micro-needling is an effective non-ablative procedure using a medical needling technique to help improve skin texture, elasticity, wrinkles and fine lines, skin crepiness, scars and stretch marks. Microscopic punctures in the skin stimulate a release of platelets which in turn generates a release of growth hormones and new skin cells. During the treatment period and for about 5 months following the treatments, treated skin experiences renewed growth, by a proliferation of fibroblast cells, responsible for collagen and elastin.
I have had an appointment and advised with Dr. Chang Soo Kim before undergoing microneedling.
My skin may be prepared with a topical anaesthetic cream. The risks, side effects, complications of these topical anaesthetics may include skin irritation (itching or redness), and much more rarely, light headedness, rapid heart rate, visual disturbances and tongue numbness.
Like any cosmetic treatment, there are no guarantees because results vary based on a number of factors such as skin deterioration, smoking, sun exposure, overall health, skin health, number of treatments, responsiveness to treatments, etc. I understand that best results are achieved when combined with skin care treatment.
During treatment, I will experience some minor bleeding. Inflammation and redness can be expected for about 2 to 48 hours. To minimize risks, I have stopped taking ASA products or anticoagulants for 5 days before my first treatment.
I have disclosed my medical history, allergies and medications. The spread of an infection can occur as well as exacerbating an existing medical condition.
I agree to advise Dr. Chang Soo Kim and the staff at The Primping Place of any changes to any medical conditions or health throughout the treatment period.
I understand that if I have active herpes, acne or skin infection, treatment may be delayed until the condition has resolved.
I understand treatment can trigger a herpes flareup.
I have disclosed my health history and do not have: skin cancer, impetigo lesions anywhere on the body, allergy to local anaesthetic agents, uncontrolled diabetes any blood OR bleeding disorders, haemophilia, HIV/AIDS; hepatitis or keloid scarring.
I am not immune compromised and/or being treated with chemotherapy, high doses of corticosteroids, or radiotherapy/
I agree to allow a staff member of The Primping Place to photograph the treatment area before treatment, at the end of the treatment and 5 months after the treatment and authorize their anonymous use for the purposes of medical audit, education and promotion.
Micro-needling is cosmetic and not medically necessary. It is not covered by my insurance plan.
I agree to allow the staff of The Primping Place to treat me and to follow-up or contact with the office if I have any issues of concern.
I agree to follow the post-treatment instructions.
I have honestly initialled every paragraph and understand what I have initialled. April 23, 2019