Microneedling Consent

ADVANCED MICRONEEDLING

Consent to Treat

Welcome to SIMPLY DAWN! We are excited for your microneedling service today. You have previously signed a Microneedling Reminders & Contraindications form which gives a comprehensive list of pre-treatment reminders, contraindications, and post-treatment information regarding your microneedling service. Please read and check each item below, signifying that you have complied with all pre-treatment reminders and are prepared to receive your microneedling procedure today. If you have any questions, please ask your practitioner prior to the start of your service. Thank you!

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PLEASE REVIEW AND CHECK ALL ITEMS BELOW:

I have been candid in disclosing any information that may have bearing on or be a contraindication to this treatment. If I am unsure, I will ask. If there have been changes in my skin, health, and/or medications, I have informed my practitioner prior to receiving treatment.

I have not started any new medications since my last treatment, including antibiotics, auto-immune therapies, or other photo-sensitizing drugs. If I have, I have informed my practitioner so my treatment may be adapted as needed.

I understand that treatment is not an exact science. The degree of improvement varies from one person to another and depends on many variables, including but not limited to: age, skin condition, extent of skin damage, lifestyle choices, health habits, commitment to proper homecare maintenance, etc.

I am not pregnant. (Safe treatments are available during pregnancy. Please discuss these options with your practitioner if applicable.)

I have discontinued use of any form of topical prescription or non-prescription vitamin A (such as Tretinoin, retinol, etc) for 48 hours prior to my scheduled appointment. I have also discontinued the use of topical AHA/BHA products for 48 hours prior to my scheduled appointment.

I do not currently have active cold sores. If I am prone to cold sores or herpes-type virus, I have begin using my antiviral medication (such as Valtrex) for at least 24 hours prior to receiving treatment.

I have not taken Accutane in the past 6 months (minimum).

I have not had a chemical peel, cosmetic injections, or any other advanced treatment within 14 days prior to my scheduled appointment.

I have not waxed the area to be treated within 7 days prior to my scheduled appointment. I also agree not to wax or use depilatories on the treated area until healing is completed and my skin has returned to normal (usually about 7 days).

I have not tanned my skin outdoors or in a tanning bed within the past 2 weeks. I also agree to avoid tanning my skin for at least 2 weeks post-treatment (preferably never). This practice should be discontinued due to increased risks of treatment complications, skin cancer, and accelerated signs of skin damage and aging.

I understand that extended UV/sun exposure is prohibited while I am undergoing treatment, and the daily use of a sunscreen with a minumum of SPF 30 is required. I understand that if I choose to expose my skin in any way to direct UV/sun light, I could possibly reverse the positive effects of this treatment and other treatments. I understand that UV exposure is the number one cause of increased risk factors and premature skin damage and aging.

I agree to notify my service provider immediately with any post-treatment questions, concerns, or complications.

I agree to use the post-treatment product kit provided to me until my skin has returned to normal (usually about 3-7 days), at which time I may resume the use of my normal recommended skincare regimen, and/or the application of active skincare topicals such as vitamin A creams, AHA/BHA-based products, benzoyl peroxide-based products, etc.

I understand that there may be a degree of activity or sensation during this procedure. I understand I may experience a feeling of mild to moderate discomfort during the active portion of the procedure, and I understand that the use of a prescription numbing cream will help to mitigate these sensations. I also understand that any active sensation is temporary and will subside immediately once the procedure is completed. Any lingering warmth, edema, tightness, skin redness, or flaking that might occur is also temporary and will resolve during the post-treatment process.

I understand that best results in skincare are achieved over the course of multiple treatments. I also understand that due to the cyclical nature of skin and body processes, I will need regular skincare treatments if I wish to improve and maintain peak results.

I understand that for best microneedling results, 4-6 procedures are typically recommended, spaced 4-6 weeks apart. I understand that microneedling procedures are safe to perform year round, and I may continue receiving microneedling procedures periodically even after a full program is completed, if desired. Upon completion of my program, I also understand that regular facial treatments and a prescribed homecare regimen are recommended to maintain and continue improving upon my beautiful results.

I was informed that a numbing cream patch test was available to me up to 48 hours prior to receiving treatment, even if I chose not to receive one.

CONTRAINDICATIONS

Advanced microneedling treatments are a safe and effective way to build collagen and improve the tone, texture, and function of the skin. However, there are a few contraindications for receiving microneedling treatments. Please review this list to ensure you are free from conditions that would prevent you from receiving a microneedling service, and contact us if you have any specific questions prior to your appointment.

Precautions and Conditional Contraindications:

History of herpes simplex (anti-viral medication must be taken 24 hours prior to receiving treatment)
Active acne breakout with pustules (mild breakout without pustules may be treated, pending consultation)
History of eczema, psoriasis or other chronic skin conditions on treatment area
Presence of large number of raised moles, warts, or raised lesions on treatment area (infrequent lesions can be avoided during treatment)
Brand new scar tissue (wounds with scarring must heal for 6 months before treating)
Open wounds on treatment area (minor wounds can be avoided during treatment)

Absolute Contraindications:

Use of Accutane (must be off for a minimum of 6 months prior to treatment)
Current use of hydrocortisone on treatment area
Active bacterial or fungal infection
Scleroderma
Visible redness, irritation, or inflammation
Active cold sores or facial rash
Active rosacea flare-ups
Abnormal lesions
Current treatment for serious medical condition (doctor’s note required)
Autoimmune disease (doctor’s note required)
Medications for diabetes, Lupus, or chemotherapy treatments
History/presence of keloids or hypertrophic scarring
Frequent use of tanning beds or frequent sun exposure
Any infectious disease
Pregnant or lactating (safe treatments are available during pregnancy; please discuss these options with your service provider prior to your scheduled appointment)

I do not have any of the contraindications listed above, and I am prepared to receive treatment.

SIGNATURE

By signing below, I acknowledge that all microneedling pre-treatment reminders, contraindications, and post-treatment guidelines have been provided to me in full, and I have reviewed them prior to receiving treatment. A list of contraindications has also been provided to me. I understand the DO’s and DON’T’s for receiving a microneedling service, and I have abided by all guidelines prior to receiving treatment. If something was unclear to me, I have consulted with my practitioner, and my questions have been answered. For my safety, I have informed my practitioner of any contraindications that may be present, or of changes in my skin, overall health, or medications prior to receiving treatment. I understand that a numbing cream patch test was made available to me up to 48-hours prior to receiving treatment, even if I chose not to receive one. If I am under a doctor’s care for any medical condition, I have consulted with my doctor prior to receiving treatment. If I am choosing to receive an advanced microneedling procedure without my doctor’s approval, I am assuming full responsibility and hereby and forever release SIMPLY DAWN [Skin Spa | Wellness Studio] from any and all liability. I understand that 1) before and after photos may be taken to document treatment results and/or processes, 2) these photos may be used by SIMPLY DAWN for business and/or marketing purposes, and 3) I may request to have my identity masked prior to posting publicly. I am either of lawful age and I am signing for myself, or I am a legal parent/guardian and I give my consent for my minor to receive treatment.

SIGNATURE

Clear

PARENT/GUARDIAN SIGNATURE (if patient is under the age of 18)

Clear

Date

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