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Medical Micro-needling History & Consent 

Microneedling is one of the best ways to stimulate the production of collagen. Using the highest quality medical Grade CE marked electronic pen device, small needles are used to prick the skin starting a healing cascade. As a result new collagen and elastin is formed reducing wrinkle depth and the appearance of scars and other skin imperfections, leaving the skin smoother, clearer, firmer and younger looking. Includes application of numbing cream, cleanse, second cleanse, enzyme peel, medical grade sterile serum chosen for your skin concern, medical grade post procedure mask and LED therapy. Micro needling is excellent for: Ageing Pigmentation Acne scarring Stretch marks Texture and tone Recommended frequency: One per month, maximum of 6 treatments per year.

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Disclaimer:

Please ensure that all consent forms are relevant to you as a practitioner and verified by your insurance company.


It is your responsibility to ensure your consent form is correct.


Prior to receiving treatment, please reveal any conditions that may have an effect on this treatment. If you are unsure of any details including personal requirements and potential complications, please discuss with your practitioner.

Please complete the following questionnaire:

Are you currently under a doctor’s or specialist’s care?
Yes
No
Do you take any over-the-counter or prescription medication or herbal/natural remedies on a regular basis?
Yes
No
Do you have any current chronic or serious medical illnesses such as diabetes, heart disease/angina, epilepsy, hepatitis, blood disorders, cancer?
Yes
No
Do you have any autoimmune diseases such as psoriasis, lupus, rheumatoid arthiritus or any condition that may weaken your immune system.
Yes
No
Do you have any known allergies including to topical anaesthetics or mesotherapy products?
Yes
No
Do you have any skin conditions such as acne, rosacea, seborrhoea, facial cold sores (herpes simplex), moles, warts, vitiligo, contact dermatitis or inflammatory skin diseases?
Yes
No
Do you have or have had any form of skin cancer?
Yes
No
Are you currently receiving chemotherapy or radiotherapy?
Yes
No
Have you taken medication for acne such as oral retinoids (Roaccutane) or benzoyl peroxide in the last 6 months?
Yes
No
Are you currently taking steroids, anti-coagulants or aspirin on a daily basis?
Yes
No
Do you have a predisposition to keloid or hypertrophic scars?
Yes
No
Have you used any products containing topical retinoids (Vitamin A, Retinol, Retin A etc) in the last week?
Yes
No
Have you used any exfoliants or products containing alpha hydroxy (AHAs), beta hydroxy (BHAs) acids (such glycolic acid, lactic acid, fruit acids) or hydroquinone in the last week?
Yes
No
Have you had any recent facial surgery or aesthetic treatments such as rhinoplasty, face lift, dermal fillers, PDO threads, Botulinum toxin, aesthetic dental work, tattoos, piercings, laser resurfacing, laser hair removal, micro needling or skin peels?
Yes
No
Have you had electrolysis, depilatory creams, or waxing on the area to be treated in the last week?
Yes
No
Have you had any recent sunburn, windburn, cuts or skin abrasions?
Yes
No
Do you smoke?
Yes
No

For women:

Are you pregnant or is there any possibility that you are pregnant?
Yes
No
Not Applicable
Are you breastfeeding?
Yes
No
Not Applicable
Are there any other aspects of your health that have not been identified above and we should be made aware of?
Yes
No
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I confirm that I understands the risks and conditions associated with Derma Roller / Micro-Needling treatment and the use of mesotherapy products and that it is an elective procedure.


The Micro-needling treatment is typically used for skin rejuvenation and improvement of scars. This treatment uses a derma roller or micro-needling medical device to create micro needle punctures that cause mild trauma to the skin’s surface to stimulate the natural production of new collagen and elastin. Mesotherapy products will be used in conjunction in order to introduce active ingredients for an enhanced and more targeted treatment.


Reactions from treatment include: skin redness and flushing, tightness, itching, tenderness, stinging, swelling and some pinpoint bleeding.


Effects will usually typically resolve within hours and many people are able to return to their normal activities the same or next day. Some people may react differently and may experience these reactions for longer. However, these reactions are temporary and typically resolve within 3-4 days as the skin returns to normal.


There is a small risk of side effects causing the skin to turn very red, blister, swell, peel and later scab and crust. In severe cases infection and ulceration may result, although this is not expected to occur due to the sterility of the derma roller/micro-needling device and the minimally invasive nature of the micro-medical needles.


Micro-needle Therapy procedure may 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.


There is a small risk that hyperpigmentation of the skin can occur after the procedure, although this is not normally expected as the epidermis of the skin is not removed as a result of the procedure. Failure to follow the advice detailed below can increase this risk.


As with the use of any product, there is also a small risk of a reaction to the mesotherapy products.


I have been given the following post treatment advice:


  • Refrain from touching the skin with your hands until the pores have had chance to close. DO NOT PICK OR PULL THE SKIN. Any redness should subside over a 24 - 36 hour period.


  • Gently wash the treated areas on the same day, but do not rub or massage the face for 2 weeks. Cleanse using a mild cleanser. It is recommended that the use of soaps, other than those recommended by your practitioner, on the treated skin area is restricted until the redness subsides and where possible lukewarm water and / or gentle skin cleansers are used for cleansing. Do not scrub. Pat to dry only with a clean towel.


  • Use of intensive moisturiser is advised for at least a week as your skin may feel drier or tighter after your treatment – this is quite normal.


  • Avoid facial products containing fragrance for 3-5 days after treatment as these may irritate the skin.


  • Make up can be applied once the skin has settled, but ensure all brushes and sponges have been cleaned.


  • Refrain from extreme temperatures such as intensive sun light, saunas, sunbed, steam bath for a period of at least 2 weeks after treatment.


  • Apply a sunscreen with an SPF30+ (such as the CLINICCARE Sun Shield Silky Cream SPF30) on a daily basis and with regular applications for a period of at least 2 weeks.


  • Avoid electrolysis, waxing, bleaching (face), depilatory creams, laser hair removal for at least 72 hours.


  • Avoid strong chlorinated water (swimming or cleaning) for approximately 14 days.


  • Please report any concerns to your practitioner as soon as possible.


I confirm that I understand the risks and conditions accociated with this treatment and that it is an elective medicalcosmetic treatment.


I confirm that the medical history and medication details that I have supplied are complete and correct and that there is no other medical information I need to disclose.


I understand that withholding any medical information may be detrimental to my health and safety during the treatment in which I agree to undertake.


If there is any change in my medical history, it is my responsibility to advise the practitioner before further treatments are carried out.


I understand that there are certain contraindications that would preclude me from receiving treatment including an active bacterial, viral, fungal, or herpetic infection, raised moles or warts, active acne, rosacea, eczema, psoriasis, facial cancers, history of radiation therapy within the application area, a history of abnormal scarring, keloids, atrophic skin, autoimmune disorders, haemophiliac, diabetes, taking anticoagulants, pregnant or breastfeeding.


I confirm that I understand the risks and conditions associated with the treatment. These have been fully explained to me and I have had the opportunity to ask any questions and these have been answered to my satisfaction.


Development of any reactions must be reported to the practitioner as soon as possible.


I accept and understand that there are no written, implied, or verbal guarantees as to the anticipated results of this treatment and that the effects of treatment will vary with some patients than with others and that the goal of this treatment is improvement, not perfection.


I may require a series of treatments, normally with at least 3-6 weeks between procedures, to achieve the maximum cosmetic result.


I have been given post treatment advice and I understand and agree to follow all the care instructions carefully to minimise the risk of side effects.


I confirm that I have been allowed sufficient time to make a carefully considered decision.


I consent to the taking of (pre and post-treatment) photographs to monitor treatment effects.


Complete patient confidentiality will be maintained at all times.

I also consent (please tick as applicable) to these photographs being used for:
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