I hereby consent to the microneedling treatment...
I consent to have my pictures and/or videos taken and stored in the electronic medical record system of [Rev Facial Bar]. Such photographs and videos will not be used for any purpose except internal training without my express permission.
I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment prior to receiving services. I further agree in the event of non-payment, cancellation of payment, or any payment issues, to bear the cost of collection, and/or the court cost and legal fees.
I consent to email, text and phone communications related to post-procedure care and follow-up appointments. I consent to receive promotional messages and marketing messages via email, phone and SMS messages from [Rev Facial Bar].
I am not aware that I am pregnant. I am not trying to get pregnant. I do not have or have not had any major illnesses which should prohibit me from receiving this treatment.
I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to, lidocaine. I am completely of sound mind and am fully aware of all the risks and possible complications of this procedure. I understand this procedure is one hundred percent voluntary. I acknowledge that no guarantee has been given regarding the results that may be obtained. I have read the material given to me and I am fully satisfied that all of my questions and concerns have been addressed.
I understand that I am required to attend post-procedure check-ups as advised by [Rev Facial Bar] and that I am required to follow all post-treatment instructions. I have received and fully understand the pre- and post-treatment instructions. I have advised my provider of my medical history including all previous medical conditions and medications currently being taken by me.
Alternatives to the procedures and options that I am choosing to get today have been fully explained to me. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications and injury. I am aware that there may be other risks or complications not discussed that may occur. I also understand that during the course of the proposed procedure, unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed.
I acknowledge that no guarantees or promises have been made to me concerning the results of this procedure or any treatment that may be required as a result of this procedure. I understand there are no refunds and that multiple treatments are often required to achieve noticeable and lasting outcomes. I also understand that promotional items have no refund value.
Microneedling procedures allow for controlled induction of the skin’s self-repair mechanism by creating micro “injuries” in the skin, which trigger new collagen synthesis. The result is smoother, younger-looking skin.
Microneedling procedures are performed in a safe and precise manner with the use of the sterile needle head. The procedure is normally completed within 30-90 minutes, depending on the required procedure and anatomical site.
After the procedure, the skin will be red and flushed in appearance, similar to a moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on certain areas. This will diminish significantly within a few hours following the procedure. Within the next 24-48 hours, the skin will have returned to normal. There may be pinpoint bruising in areas that were treated more aggressively that will resolve in the next 24-72 hours. After three days, there is rarely any evidence that the procedure has taken place.
Microneedling is contraindicated for patients with: keloid scars, scleroderma, collagen vascular diseases or cardiac abnormalities, a hemorrhagic disorder or hemostatic dysfunction, active bacterial or fungal infection, or active cold sores, or any history of cold sores on the cheeks or nose.
Microneedling has not been evaluated in the following patient populations, and as such, precautions should be taken when determining whether the microneedling procedure is adequate for the patient: scars and stretch marks less than one year old; women who are pregnant or nursing; keloid scars; patients with history of eczema, psoriasis and other chronic conditions; patients with history of actinic (solar) keratosis; patients with history of herpes simplex infections; diabetics or patients with wound- healing deficiencies; patients on immunosuppressive therapy; and skin with presence of raised moles or warts on targeted area.
I have been instructed in and understand the post-treatment instructions. I have been given sufficient information to enable me to understand the use of these products. I have also received information regarding contraindications to the administration of products and potential side effects.
Post-treatment I agree to comply with the following instructions:
Avoid sun exposure and saunas and working out for 24 hours.
Avoid manipulation of the treated area and make up, as instructed by the practitioner. Some redness, swelling, hematomas and bruising may occur following treatment. Resolution is typically spontaneous within a few days. Persistence of any inflammatory reaction for more than one week or the development of any other side effects must be reported to the practitioner as soon as possible. I understand some clients may experience a hypersensitive reaction to Hibiclens®, alcohol, or acetone, or to other prep or cleaning solutions.
ARBITRATION AGREEMENT – READ CAREFULLY
It is understood and agreed by [Rev Facial Bar] and I, as a recipient of services, that any legal dispute, controversy, demand or claim that arises out of or relates to the services provided to me by [Rev Facial Bar] or any other service provided by [Rev Facial Bar] to me shall be resolved exclusively by binding arbitration as provided by [New York State] law.
It is understood that any dispute as to medical malpractice (whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompletely rendered) will be determined by submission to arbitration and not in a court of law or before a jury.
It is in the intent of the parties that this agreement cover all existing or subsequent claims or controversies, whether in tort, contract, or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to the treatment of services provided or not provided by any employee, physician, association, partner, or agent affiliated with [Rev Facial Bar] to a patient. This party includes causes of action that might be brought on behalf of me by a spouse, heir, child (born or unborn), guardian or parent.
I read, write and fully understand English. I am of sound mind and body and have the full capacity to consent to this treatment.
By accepting and signing this consent, I acknowledge that I have read this informed consent, I understand it, and I agree to this treatment with its associated risks. I hereby give consent to perform this and all subsequent treatments with the above understood. I hereby release the Medical Director(s), [Rev Facial Bar] and the provider performing the treatment from liability associated with this procedure. I have been given the opportunity to ask questions and my questions have been answered to my satisfaction. I hereby consent to the microneedling treatment and hereby authorize the [Rev Facial Bar] provider to perform the treatment.