Microneedling/Hair Rejuvenation

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Microneedling/Hair Rejuvenation - Consent Form

Name

Would you like to be added to our VIP client list to receive exclusive offers for those who sign up and includes specials etc. each month? If yes, enter your email below...

Date

YYYY

I hereby give permission for photographs of the intended treatment site for diagnostic purposes and to enhance the medical record. I agree that these photographs will remain the clinic’s property. I further authorize to use these photographs for marketing purposes. It is specifically understood that in any such publication or use. *

I consent

I DO NOT consent

Are you interested in purchasing a dermaroller for home care use between your professional treatments? We highly recommend this for best results. *

Yes

Are you interested in upgrading to the organic option for your Micro-Needling for $30 extra? We use a high grade, organic serum instead of a synthetic/lab made one. *

Yes

I am requesting a eDermaStamp: Collagen Induction/Scar Reduction/Hair Growth treatment of the skin for fine wrinkles, acne scaring or skin changes associated with actinic damage or ageing, and voluntarily by consent authorize this procedure. The preferred areas to be treated are: *

I understand that eDermaStamp Treatment utilizes fine micro-needles to puncture into the skin surface. As a consequence, the repair process releases numerous growth and healing factors that stimulate new collagen to be deposited under the skin surface. The repair process will actually extend over a twelve to sixteen week period after treatment. I also understand that I may require a series of treatments to achieve the maximum cosmetic result. The procedure and complications have been explained to me and I have had the opportunity to have my questions answered. I have been advised that the object of the procedure I have requested is improvement in appearance, not perfection. It is possible for imperfections to persist, and that the result might not live up to my expectations or goals. I fully understand that the service provider cannot guarantee results. I acknowledge that no written or implied verbal guarantee, warranty, or assurance has been made to me regarding the outcome of the procedure that I herein requested and authorized. I also understand the limitations of this procedure. *

I Understand

Erythema: The skin may remain red for generally 24 hours up to four days after eDermaStamp treatment. As the skin heals the erythema will resolve. *

I Understand

I understand that a eDermaStamp can be combined with the application of serums, nutritional factors, and vitamins to stimulate optimal collagen production. *

I Understand

Other:

I understand bruising may occur as a result of treatment. *

I Understand

Other:

Hyper-pigmentation: A small number of patients may experience a hyper-pigmentation of the skin surface (especially if the skin is exposed to the sun). *

I Understand

I understand that in order to avoid possible adverse reactions I need to refrain from any intensive sun exposure and/or solarium for a period of 2 weeks. I shall use a sun block with a protection factor of 15 or higher. *

I Understand

I shall follow the prescribed post procedure skin care to avoid infection. *

I Understand

Other:

I understand that the post-treatment care regime is recommended with designated Dermaroller products which were specifically formulated for the treatment. *

I Understand

I understand that I may require additional treatments in order to achieve maximum results and that some imperfections are not amenable to a eDermaStamp treatment. *

I Understand

Other:

I understand that prior to treatment I must provide the treating clinician with any information regarding my former skin conditions and illnesses, including personal history of herpes simplex. *

I Understand

Other:

I understand that patients with a history of herpes simplex (cold sores) may experience a flare up of the disease. *

I Understand

Option 2

I understand that infection is a rare possibility. *

I Understand

I agree to follow the instructions given to me by the clinic to the best of my ability before, during, and after the procedure. I understand that patient responsibility and proper performance of the post-treatment care are critical to the success of the treatment. I have thoroughly read and understand the instructions and reviewed them with the treatment provider. I acknowledge that I have read and filled out the patient registration and medical history form fully and correctly to the best of my knowledge, and that the information that I have supplied is correct. *

I agree

I DO NOT agree

Date * *

YYYY

Please type full name to agree to all terms and conditions *

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