Vampire Facial Consent

{ binding firstError.message }
{ binding firstError.message }

PROCEDURE:

The concept of micro-needling is based on the skin’s natural ability to repair itself when it suffers physical damage such as cuts, burns, abrasions or other injuries. Immediately after an injury to the skin, our body begins the healing process, triggering new collagen synthesis. Micro-needling works by intentionally creating very superficial “micro-injuries” to the outermost later of the skin, inducing the healing process including new collagen production. Micro-needling has been shown to reduce the visibility of acne scars, fine lines, and wrinkles, diminish hyperpigmentation, and improve skin tone and texture, resulting in smoother, firmer, younger looking skin. The micro-needling procedure is performed in a safe and precise manner with a single-use sterile needle head. The treatment session usually takes about 30-60 minutes, depending on the area(s) being treated. After the procedure, the skin will be red, with mild swelling and/or bruising. It might also feel tight and sensitive to the tough. Although these symptoms may take 2-3 days to resolve completely, they will diminish significantly within a few hours after treatment.

ALTERNATIVE TREATMENTS:

Alternative treatments to micro-needling may include the use of routine skin care, oral and/or topical prescription and/or non-prescription medications, microdermabrasion, dermalplaning, laser treatments, and even surgery. Each of these alternatives carries their own inherent risks and benefits. However, since this treatment is elective and is done for cosmetic purpose only, no treatment at all should also be considered as a viable alternative.

RISK:

Although the majority of patients do not experience any complications with micro-needling, it is important that you understand that risks do exist. The micro-needling procedure is minimally invasive, utilizing a set if micro-needles to inflict multiple, tiny, puncture/lacerations to the outermost later of the skin. Because micro-needling penetrates the skin, it inherently carries health risks, including but not limited to those listed below. You should discuss any and all health concerns with your esthetician PRIOR to signing this consent form.

INFECTION:

  • Infection is very unusual. However, viral, bacterial, and fungal infections can occur anytime the integrity of the skin is compromised. Should infection occur, you must contact or return to our office immediately, as additional treatment will likely be necessary.

PIGMENT/COLOR CHANGE:

  • Because dermal penetration is so superficial it does not extend into the layer of the skin containing melanocytes, hyperpigmentation is very rare with micro-needling; however, failure to follow post treatment instructions can put you at risk for hyperpigmentation. You MUST avoid sun exposure for 1-2 weeks after treatment. You should also wear a daily SPF facial moisturizer, which your esthetician can recommend. Lastly, avoid picking and/or peeling the skin during the healing process.

SCARRING:

  • Although normal healing after the procedure is expected, abnormal scars may occur in both the skin and deeper tissues. In rare cases, thickened or keloid scars may result, especially if you are prone to keloid scarring. Scars may be unattractive or of different color than the surrounding skin. Additional treatments may be necessary.

PAIN:

  • There may be a very slight burning, scratchy, and/or irritated sensation to the skin. This is usually temporary and is gone within a few hours after treatment. A sudden reappearance of redness or pain is a sign of infection and you should notify our office immediately.

PERSISTENT REDNESS, ITCHING, AND/OR SWELLING:

  • Itching, redness, and swelling are normal parts of the healing process. These symptoms rarely persist longer than 24 hours with micro-needling. However, treatments received less than 4 weeks apart may induce prolonged symptoms.

ALLERGIC REACTION:

  • Micro-needling is performed with a head containing 12 sterile hypodermic needles, making an allergic reaction nearly impossible; however, a variety of products may be used on the face in conjunction with the procedure, to which an allergic reaction can occur. Additionally, since micro-needling increases the penetration of topical substances, it can cause you to be hypersensitive to products used on the face. If an allergic reaction were to occur, you should notify our office immediately.

LACK OR PERMANENT RESULTS:

  • This procedure will not completely or permanently improve skin texture, tone, elasticity, hyperpigmentation, scars, or minimize fine lines and wrinkles. It is important that your expectations be realistic and understand that the procedure has limitations. Additional procedures may be necessary to achieve desired effects.

UNSATISFACTORY RESULTS:

  • Although rare, there is a possibility of a poor result from any cosmetic procedure. Micro-needling may induce undesirable results, including bot not limited to skin sloughing, scarring, permanent pigment, and/or other undesirable skin changes.

CONTRAINDICATIONS TO MICRO-NEEDLING:

It is important to list every potential risk and complication; the following are recognized as known contraindications to micro-needling. It is your responsibility to fully and accurately disclose as medical history prior to initial treatment, as well as provide any necessary updates at all future treatment sessions. If you have any of the conditions listed below, you should bring it to the attention of your esthetician PRIOR to signing this consent form.

  • Active acne
  • Active infection of any type (bacterial, viral, or fungal)
  • Blood thinner medications
  • Cardiac disease/abnormalities
  • Chemotherapy or radiation
  • Collagen vascular disease
  • Eczema, psoriasis, or dermatitis
  • Hemophilia/bleeding disorders
  • Hormone replacement therapy
  • Keloid/hypertrophic scaring
  • Pregnancy/lactation
  • Raised lesions (moles, warts, etc.)
  • Recent chemical peel procedures
  • Recent use of some topical rx
  • Rosacea
  • Scleroderma
  • Skin cancer
  • Sunburn
  • Tattoos
  • Telangiectasia/erythema
  • Uncontrolled diabetes
  • Vascular lesions (hemangiomas)

CONSENT:

My signature below acknowledges that I have read and understand the content of this informed consent. I have been given ample opportunity to ask questions, all of which have been answered in a satisfactory manner. I understand that results can vary and that no guarantee, neither expressed nor implied, has been or will be, give to me regarding my results. I am aware of the risk and benefits associated with the micro-needling procedure, as well as alternative treatments. I understand the micro-needling is an elective procedure, preformed solely for cosmetic purposes. On my own free will, I am requesting and providing my informed consent, to undergo micro-needling treatment(s).

{ binding firstError.message }
{ binding firstError.message }

Vampire Facial Consent

Vampire Facial Consent

Patient First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Patient Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

PROCEDURE:

The concept of micro-needling is based on the skin’s natural ability to repair itself when it suffers physical damage such as cuts, burns, abrasions or other injuries. Immediately after an injury to the skin, our body begins the healing process, triggering new collagen synthesis. Micro-needling works by intentionally creating very superficial “micro-injuries” to the outermost later of the skin, inducing the healing process including new collagen production. Micro-needling has been shown to reduce the visibility of acne scars, fine lines, and wrinkles, diminish hyperpigmentation, and improve skin tone and texture, resulting in smoother, firmer, younger looking skin. The micro-needling procedure is performed in a safe and precise manner with a single-use sterile needle head. The treatment session usually takes about 30-60 minutes, depending on the area(s) being treated. After the procedure, the skin will be red, with mild swelling and/or bruising. It might also feel tight and sensitive to the tough. Although these symptoms may take 2-3 days to resolve completely, they will diminish significantly within a few hours after treatment.

ALTERNATIVE TREATMENTS:

Alternative treatments to micro-needling may include the use of routine skin care, oral and/or topical prescription and/or non-prescription medications, microdermabrasion, dermalplaning, laser treatments, and even surgery. Each of these alternatives carries their own inherent risks and benefits. However, since this treatment is elective and is done for cosmetic purpose only, no treatment at all should also be considered as a viable alternative.

RISK:

Although the majority of patients do not experience any complications with micro-needling, it is important that you understand that risks do exist. The micro-needling procedure is minimally invasive, utilizing a set if micro-needles to inflict multiple, tiny, puncture/lacerations to the outermost later of the skin. Because micro-needling penetrates the skin, it inherently carries health risks, including but not limited to those listed below. You should discuss any and all health concerns with your esthetician PRIOR to signing this consent form.

INFECTION:

  • Infection is very unusual. However, viral, bacterial, and fungal infections can occur anytime the integrity of the skin is compromised. Should infection occur, you must contact or return to our office immediately, as additional treatment will likely be necessary.

PIGMENT/COLOR CHANGE:

  • Because dermal penetration is so superficial it does not extend into the layer of the skin containing melanocytes, hyperpigmentation is very rare with micro-needling; however, failure to follow post treatment instructions can put you at risk for hyperpigmentation. You MUST avoid sun exposure for 1-2 weeks after treatment. You should also wear a daily SPF facial moisturizer, which your esthetician can recommend. Lastly, avoid picking and/or peeling the skin during the healing process.

SCARRING:

  • Although normal healing after the procedure is expected, abnormal scars may occur in both the skin and deeper tissues. In rare cases, thickened or keloid scars may result, especially if you are prone to keloid scarring. Scars may be unattractive or of different color than the surrounding skin. Additional treatments may be necessary.

PAIN:

  • There may be a very slight burning, scratchy, and/or irritated sensation to the skin. This is usually temporary and is gone within a few hours after treatment. A sudden reappearance of redness or pain is a sign of infection and you should notify our office immediately.

PERSISTENT REDNESS, ITCHING, AND/OR SWELLING:

  • Itching, redness, and swelling are normal parts of the healing process. These symptoms rarely persist longer than 24 hours with micro-needling. However, treatments received less than 4 weeks apart may induce prolonged symptoms.

ALLERGIC REACTION:

  • Micro-needling is performed with a head containing 12 sterile hypodermic needles, making an allergic reaction nearly impossible; however, a variety of products may be used on the face in conjunction with the procedure, to which an allergic reaction can occur. Additionally, since micro-needling increases the penetration of topical substances, it can cause you to be hypersensitive to products used on the face. If an allergic reaction were to occur, you should notify our office immediately.

LACK OR PERMANENT RESULTS:

  • This procedure will not completely or permanently improve skin texture, tone, elasticity, hyperpigmentation, scars, or minimize fine lines and wrinkles. It is important that your expectations be realistic and understand that the procedure has limitations. Additional procedures may be necessary to achieve desired effects.

UNSATISFACTORY RESULTS:

  • Although rare, there is a possibility of a poor result from any cosmetic procedure. Micro-needling may induce undesirable results, including bot not limited to skin sloughing, scarring, permanent pigment, and/or other undesirable skin changes.

CONTRAINDICATIONS TO MICRO-NEEDLING:

It is important to list every potential risk and complication; the following are recognized as known contraindications to micro-needling. It is your responsibility to fully and accurately disclose as medical history prior to initial treatment, as well as provide any necessary updates at all future treatment sessions. If you have any of the conditions listed below, you should bring it to the attention of your esthetician PRIOR to signing this consent form.

  • Active acne
  • Active infection of any type (bacterial, viral, or fungal)
  • Blood thinner medications
  • Cardiac disease/abnormalities
  • Chemotherapy or radiation
  • Collagen vascular disease
  • Eczema, psoriasis, or dermatitis
  • Hemophilia/bleeding disorders
  • Hormone replacement therapy
  • Keloid/hypertrophic scaring
  • Pregnancy/lactation
  • Raised lesions (moles, warts, etc.)
  • Recent chemical peel procedures
  • Recent use of some topical rx
  • Rosacea
  • Scleroderma
  • Skin cancer
  • Sunburn
  • Tattoos
  • Telangiectasia/erythema
  • Uncontrolled diabetes
  • Vascular lesions (hemangiomas)

CONSENT:

My signature below acknowledges that I have read and understand the content of this informed consent. I have been given ample opportunity to ask questions, all of which have been answered in a satisfactory manner. I understand that results can vary and that no guarantee, neither expressed nor implied, has been or will be, give to me regarding my results. I am aware of the risk and benefits associated with the micro-needling procedure, as well as alternative treatments. I understand the micro-needling is an elective procedure, preformed solely for cosmetic purposes. On my own free will, I am requesting and providing my informed consent, to undergo micro-needling treatment(s).

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }