Topical Rx Anesthetic Consent

TOPICAL Rx ANESTHETIC

Informed Consent

Name

First

Last

Address

City

State

Zip

Email

Mobile Phone

CONSENT

In order to provide the most comfortable and effective treatment possible, we offer the use of a prescription strength compounded BLT topical anesthetic cream to help alleviate possible discomfort associated with microneedling and/or other cosmetic procedures. We will provide this cream for you to apply 30 minutes prior to the start of your treatment. We account for this window in the booking of your appointment. Please arrive for your appointment on time as scheduled - with clean, makeup-free skin - to ensure a maximum numbing effect prior to receiving treatment.

PRESCRIPTION BLT CREAM ACTIVE INGREDIENTS: 20% Benzocaine, 8% Lidocaine, 6% Tetracaine

PLEASE REVIEW AND CHECK ALL ITEMS BELOW:

I agree to avoid use of this product if I have a history of allergies associated with any anesthetic in the “caine” family of anesthetics.

I agree to consult with a health care practitioner ** prior to use of this product if I have a heart condition, pacemaker, implanted defibrillator, cardiac arrhythmia, prosthetic heart valve, cardiac dysrhythmia, epilepsy, or any history of seizure or other seizure-related disorder. (**If you need a medical referral, please let us know well in advance of your appointment and we will refer you to our medical provider who will schedule a televisit with you prior to your appointment. This is a separate appointment and is unrelated to your microneedling procedure. The televisit charge by our medical provider is $50.)

Although serious allergic reaction to this product is rare, I agree to seek immediate medical attention if I develop a new/worsening rash, new/worsening itching, severe swelling, dizziness/vertigo, seizures/tremors/convulsions, trouble breathing, tachycardia (racing heart rate), or a slow or irregular heartbeat.

I understand that minor allergic reactions are also uncommon but may include generalized hives, itchiness, flushing, or edema in the treated area.

If I am unsure whether I have an allergy to topical anesthetics, I agree to schedule a patch test at least 48 hours prior to my scheduled treatment.

I understand the possible risks and/or side effects of using the specified prescription topical anesthetic cream as disclosed above. I have no known allergies to any type of “caine” anesthetic, and I have properly disclosed any and all medical conditions and current medications on both my Client Intake form and also to my clinician prior to receiving treatment.

If this is not the first advanced skin care treatment I have received at SIMPLY DAWN, I have disclosed any recent changes in medical conditions or current medications to my clinician as indicated by signing the Microneedling Reminders & Contraindications form.

I give my consent to use the above specified prescription topical anesthetic cream prior to and during my microneedling and/or other cosmetic procedure at SIMPLY DAWN.

SIGNATURE

Clear

Date

QUICK LINKS

CONTACT US:

WELLNESS PROGRAMS: