Microneedling with SkinPen® Patient Consent Form

DESCRIPTION OF THE PROCEDURE

Microneedling procedures allow for controlled induction of the skin’s self-repair mechanism by creating micro“injuries” in the skin, which triggers new collagen synthesis. The result is smoother, younger-looking skin. Microneedling procedures are performed in a safe and precise manner with the use of the sterile needle head. The procedure is normally completed within 30–60 minutes, depending on the required procedure and anatomical site.

SIDE EFFECTS

After the procedure, the skin will be red and flushed in appearance, similar to a moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on certain areas. This will diminish significantly within a few hours following the procedure. Within the next 24-48 hours, the skin will have returned to normal. After three days, there is rarely any evidence that the procedure has taken place.

CONTRAINDICATIONS

Microneedling is contraindicated for patients with keloid scars, scleroderma, collagen vascular diseases or cardiac abnormalities, a hemorrhagic disorder or hemostatic dysfunction, and active bacterial or fungal infection.

PRECAUTIONS AND WARNINGS

Microneedling has not been evaluated in the following patient populations, and as such, precautions should be taken when determining whether the SkinPen procedure is adequate for the patient: scars and stretch marks less than one year old; women who are pregnant or nursing; keloid scars; patients with a history of eczema, psoriasis, and other chronic conditions; patients with a history of actinic
(Solar) keratosis; patients with a history of herpes simplex infections; diabetics or patients with wound-healing deficiencies; patients on immunosuppressive therapy; and skin with the presence of raised moles or warts on the targeted area.

PATIENT CONSENT

I understand that results will vary among individuals. I understand that although I may see a change after my first procedure, 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, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the procedure. I am aware that the micro-needling procedure is not permanent and natural degradation may occur over time.
I state that 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 procedure including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner.

I take full liability and responsibility for any and all risks, undesired outcomes, or adverse events associated with the injections and will not hold the providers or liable for any unfavorable outcome or adverse event. I release Sei Tu Bella Aesthetics LLC, owners, and medical staff from liability associated with the procedure. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I relieve Heather Merlo, APRN, FNP-C, Medical
Director Dr. Fernando Jara and Sei Tu Bella Aesthetics LLC, from all legal action pertaining to this treatment.