PATIENT INFORMED CONSENT FOR MICRONEEDLING

The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor prior to signing the consent form.
RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Although microneedling is effective in most cases, no guarantees can be made. I understand I may not experience complete clearance, and that it may take multiple treatments. Some conditions may not respond at all and, in rare cases, may become worse.
  • DISCOMFORT/ PAIN – Some discomfort may be experienced during treatment. Pain may include the feeling of burning, stinging and itch
  • REDNESS/ITCH/IRRITATION – These reactions are common, mild, and usually resolve in a few days
  • ACNE BREAKOUT – Rare but possible. Call us if this occurs and we can treat you.
  • SKIN COLOR CHANGES – During the healing process, there is a slight possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.
  • REACTIVATION OF HERPES (COLD SORES) – Please let us know in advance if you have a history of cold sores.
  • INFECTION – Infection is a rare possibility whenever the skin surface is disrupted, though proper wound care should prevent this. If signs of infection develop, such as pain, heat or surrounding redness, please call our office (504.226.7873).
  • SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin’s surface is disrupted. To minimize the chances of scarring, it is
  • SUN EXPOSURE / TANNING BEDS / ARTIFICIAL TANNING / SMOKING – Increases your risk of side effects and adverse events.
RELATIVE CONTRAINDICATIONS
By signing below, I confirm that I do not have any of the conditions listed below or that I have discussed them with Dr. Holcomb/Dr. Haseltine
  • Pregnant or planning pregnancy
  • History of cold sores in the area to be treated
  • Keloid scars
  • History of hemophilia, irregular blood pressure, tuberculosis, liver function issues
  • Susceptibility to capillary ectasia due to steroid use for extended periods
  • Scleroderma
  • Collagen vascular disease
  • Active bacterial or fungal infection
RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue treatment at any time.

ALTERNATIVE TREATMENTS: Laser treatments or doing nothing. If nothing is done, your skin will look the age it is now and continue to age
as you naturally would.

PHOTOGRAPHIC DOCUMENTATION WILL BE TAKEN.
ACKNOWLEDGMENT
BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR MICRONEEDLING TREATMENT, THAT THE BENEFITS AND RISKS HAVE BEEN EXPLAINED TO ME, THAT ALTERNATIVES HAVE BEEN DISCUSSED, INCLUDING DOING NOTHING, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.