I hereby give my consent to undergo Micr-needling treatments.

I understand this technique involves the introduction of fine needles through the skin. The
purpose is to create micro-channels in the skin allowing the infusion of active ingredients (such
as vitamin C, hyaluronic acid and others) to penetrate deeply and effectively into the dermis,
nourishing the skin and stimulating the regrowth of collagen. A series of 4 to 6 treatments are
recommended and the frequency will depend on the intensity and depth of the needle.

I understand that the treatments require many small injections on the area(s) to be treated. I
understand that the administration of numbing creams may be used if deemed needed.

Micro-needling is not suitable in these circumstances:

• Have used Accutane (isotretinoin) within the last year.
• Have open wounds, cuts or abrasions on the skin
• Have had radiation treatment to the skin within the last year
• Have any kind of current skin infection, condition, herpes simplex in the area to be treated
• Are pregnant or breast feeding
• Have any history of keloid or hypertrophic scars or poor wound healing

I understand that there are some risks with any procedure. The following are possible reactions with Micro-needling: temporary bruising, skin discomfort during injections, redness or swelling, lightening or darkening of the skin, itching and burning. Skin infection is a possibility any time an injection or surgical procedure is done. Side effects are most of the time temporary and typically resolve within 3 days. Total healing time depends on the depth of the treatment, skin type, and skin condition, and some patients may heal completely in 24 hours.

Your consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, you hereby grant authorization to our medical staff to perform and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.

The nature and purpose of this elective procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been offered a written copy of them. I understand that no refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.

I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given me and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history I will notify the office.

I hereby give my voluntary consent to this elective procedure and release the facility, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

I agree, if I should have any questions or concerns regarding my treatment / results I will notify this office at immediately so that timely follow-up and intervention can be provided.