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Health Waiver - Microneedling

How are you feeling today?

First Name

Last Name

Email

I am voluntarily consenting to a microneedling of the skin.

I understand that the procedure can result in an appearance enhancement and is typically used for skin rejuvenation and scar repair. The treatment uses a microneedling medical device that creates controlled micro-medical needle punctures of the skin surface.

I also understand that I may require a series of microneedling treatments, generally with at least four weeks between procedures, to achieve the maximum cosmetic result.

I acknowledge that no written or implied verbal guarantee, warranty or assurance has been made regarding the procedure’s outcomeI acknowledge that no written or implied verbal guarantee, warranty or assurance has been made regarding the procedure’s outcome

I understand the following:

Immediately after the Derma Roller procedure, the skin will be red, resembling moderate sunburn; as the skin naturally heals, the redness will resolve. The skin may remain red for three to four days after the Derma Roller treatment, although it is usual for it to subside within two days, and many people can return to their normal activities the same or the next day.

It is recommended that the use of soaps on the treated skin area is restricted until the redness subsides and where possible warm/tepid water and/or gentle skin cleansers are used for cleansing. If you are taking any medication or dietary supplements that can affect platelet function and bleeding time, the period of redness can be extended.

There is a small risk of infection of the treated skin area after the Derma Roller procedure. However, this is not expected to occur due to the sterility of the Derma Roller medical device and the minimally invasive nature of the micro-medical needles. Derma Roller procedure can cause areas of bruising, although this would not normally be expected to occur, the eye contour being the area at most risk.

Any such bruising will be temporary. If you are taking any medication or dietary supplements that can affect platelet function and bleeding time, the severity and period of bruising can be extended; also, the presence of petechiae (small red or purple spots beneath the skin) may be observed.

Any such bruising will be temporary. If you are taking any medication or dietary supplements that can affect platelet function and bleeding time, the severity and period of bruising can be extended; also, the presence of petechiae (small red or purple spots beneath the skin) may be observed.

There is a small risk that hyper-pigmentation of the skin can occur after the procedure. However, this is not generally expected as the skin’s epidermis is not removed due to the procedure. Failure to follow the sun exposure and sun protection advice detailed below can increase this risk.

I understand/confirm the following:

I don't have a history of anaphylactic shock.

I do not suffer from any allergies that I know of and I'm not allergic to local anaesthetics.

I have not taken oral retinoids (Roaccutane) in the last 12 months.

I am not using topical retinoids/Vitamin A products.

I do not have active acne with papules or pustules.

I am not taking Aspirin, Warfarin, other anti-coagulant treatments or any other medication or dietary supplements such as Omega-3 that can affect platelet function and bleeding time.

I do not have or have had any form of skin cancer.

I am not taking/receiving steroids, chemotherapy or radiotherapy.

I am not taking any medication that can interfere with this treatment. (Please check with GP if unsure).

I do not suffer from any illness, e.g. diabetes, angina, epilepsy, hepatitis, autoimmune disease.

I do not suffer from keloid or hypertrophic scars

I do not have herpes simplex (cold sores) / I do not currently have a cold sore flare up or history of other skin infections.

I have not undergone any laser resurfacing or skin peel in the last 4 weeks.

I am not pregnant, or possibly pregnant, nor am I breastfeeding.

I will refrain from intensive sunlight exposure and/or artificial UV exposure for a period of at least 2 week. I will use topical sun protection.

I will use topical sun protection products with an SPF of 30+ or higher and with stated UVA/UVB protection daily with regular applications for the same period.

I confirm that, to the best of my knowledge that the information that I have supplied is correct and that there is no other medical information I need to disclose. I understand that the practice of medicine and surgery is not an exact science. Therefore, no guarantee can be given o the results of the treatment referred to in this document. I accept and understand that the goal of this treatment is an improvement, not perfection and that there is no guarantee that the
anticipated results will be achieved.

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