Microneedling Consent Form

I have been informed understand the following about microneedling:

1. The effect, nature, purpose and gravity of the special procedure or treatment;
2. The probate discomforts, probable, special and unusual risks, potential side effects and complications of treatment and that it is impossible to identify every potential complication.
3. These may include allergic reactions to topical substances applied before, during, or after the procedure (including anaphylaxis). Allergic reactions may be delayed for up to several weeks. Topical anesthetic may also lead to cardiac arrest due to lidocaine toxicity. Short-term considerations include pain, redness (may be prolonged for several weeks in rare cases), slight burning sensation, swelling, bruising, rash, temporary track marks, secondary infection, triggering of HSV (cold sores), pustules, acne. Longterm considerations include hyperpigmentation, granulomas and scarring. The influence of the immune response to microneedling in autoimmune diseases (Lupus, Rheumatoid Arthritis etc.) is unknown.
4. The reasonable benefits obtainable by the treatment and the likelihood of success; but acknowledge that no representations, warranties, guarantees nor assurances can or have been given as to the results that may be obtained. Multiple treatments are required for optimal results.

I am currently not pregnant or breastfeeding. I agree to contact The Madison for consent to use any other medication, supplement, or topically applied substance not currently entered on my history intake form, with the knowledge that photosensitizers increase risk of hyperpigmentation after microneedling, as does sun exposure. I am also aware that sun exposure for 4 weeks after treatment may negate collagen production due to the effects of UVR. I am aware that microneedling magnifies the effects of topically applied substances and agree to only use what has been recommended, as not all skin care products are suitable or safe to use in combination with microneedling. I agree to refrain from using any chemical peels, (TCA, glycolic, salicylic acid etc.) with microneedling.