Please Complete The Following Consent Form
The purpose of this consent form is to provide written information regarding the risks, benefits and alternatives of treatment for microneedling with/or without platelet-rich plasma (PRP). This material serves as a supplement to the discussion you have with your BLOOM HEALTH provider. It’s important that you fully understand this material, so please read this information thoroughly. If you have any questions regarding the procedure, ask your BLOOM HEALTH provider prior to signing this consent form.
TREATMENT GOALS AND DESCRIPTION OF PROCEDURE
Microneedling with PRP is a form of collagen induction therapy, and is used for a number of purposes, including reduction of fine lines, wrinkles, scarring, hyperpigmentation, and for skin rejuvenation and skin tightening. Microneedling involves using a motorized pen with tiny needles to create controlled microscopic injuries over the skin. PRP is applied during the microneedling treatment, either topically or with focal injections. The combination of microneedling with PRP stimulates collagen and elastin production, nurturing the extracellular matrix and a network of new blood vessels. Treatment is usually tolerated without any significant difficulty. A topical numbing cream is applied prior to treatment to ensure comfort throughout the procedure. PRP is derived from an intravenous blood draw, taken prior to the microneedling treatment. Your blood sample is processed using a centrifuge machine, producing a highly concentrated serum rich in platelets, growth factors and cytokines. Following the procedure, a temporary sunburn like effect is normal, and the skin may feel tight, dry, and sensitive to touch for a number of days.
TREATMENT RESULTS
Most patients are pleased with the results of their microneedling treatment. However, like any aesthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that your skin condition will disappear completely, or that you will not require additional treatment to achieve the results you seek. Usually multiple microneedling treatments are needed to achieve a full effect, with a recommendation of 3 initial treatments, spaced every 4 weeks apart. Additional treatments may be required periodically, generally every 6-12 months. The results of treatment are dependent on many factors including but not limited to: age, sex, tissue conditions, your general health and lifestyle conditions, and sun exposure.
AFTERCARE INSTRUCTIONS
Following your microneedling procedure, we’ll provide you with verbal and/or written aftercare instructions. These include, but may not be limited to the following: 1) Wait 6-8 hours post-treatment to cleanse your face; 2) Use a gentle cleanser twice daily, and apply calming moisturizer with SPF as often as needed; 3) Apply recommended serums, peptides, growth factors, and antioxidants; 4) Avoid makeup for 24-72 hours; 5) Avoid “active” skincare products such as AHAs, BHBs, or retinoids for 1 week; 6) Avoid vigorous exercise, sauna, jacuzzi or swimming for 72 hours; 7) Avoid intentional sun exposure for 7 days; 8) Abstain from facial laser treatments, microdermabrasion, facial peels, and chemical peels for at least 2 weeks; 9) If at any time you suspect you’re having an unexpected side effect, adverse reaction or complication, contact us immediately, and obtain help in an appropriate medical setting (i.e., BLOOM HEALTH, your primary care provider, specialist, urgent care, or acute care facility). I will adhere to the aftercare instructions supplied to me during my visit.
POTENTIAL RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy. I understand that there are certain inherent and potential risks and side effects in any invasive procedure, and in this specific instance such risks include but are not limited to: 1) Temporary redness and mild sunburn-like effect which may last up to 3-4 days; 2) Minor flaking or dryness of the skin, and in rare cases scab formation; 3) Milia (small white bumps) may form, these can be removed; 4) Rarely, post treatment bacterial, and/or fungal infection requiring further treatment; 5) Rarely, post treatment hyper-pigmentation, which usually resolves after a month; 6) Very rarely, injury to a nerve or blood vessel during blood draw; 7) Post treatment discomfort, swelling, and bruising.
PREGNANCY AND CONTRAINDICATED CONDITIONS
I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have active herpes, active cold sores, psoriasis, warts, raised moles, sunburn, or active skin infection. I have not taken Accutane in the past six months. I have not had laser treatment, waxing, or chemical peel in the last week. I have not applied retinoids, topical antibiotics, exfoliants, hydroquinone, benzoyl peroxide or acids in the past 5-7 days.
ALTERNATIVE THERAPY
I understand that microneedling with PRP is an elective procedure with goal of improved aesthetic appearance and that the main alternative to therapy is to observe and not receive any treatment. Other available therapies might include sun protection, moisturizers, injectables, skin resurfacing, or surgery.
PAYMENT
I understand that microneedling with PRP is not covered by insurance, and payment is my responsibility and is expected at the time of treatment.
RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue my microneedling treatment at any time.
RELEASE OF LIABILITY
I hereby indemnify BLOOM HEALTH, PLLC from any liability relating to the procedures that I have volunteered for. I understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-treatment questions or concerns to the treating clinician. Furthermore, I hereby indemnify the facility/meeting room/hotel where this treatment is being performed from any liability relating to the procedures that I have volunteered for.
CONSENT TO TREATMENT
By entering my initials below, I hereby voluntarily consent to treatment with microneedling with/or without PRP for the purpose of general skin rejuvenation and improvement of wrinkles, hyperpigmentation, scarring and acne, as performed by my BLOOM HEALTH provider, and assistant technicians. I have read the above and understand it. I state that I read and write in English. I am not under the influence of drugs or alcohol. The treatment has been fully explained to me and my questions have been answered satisfactorily. I accept the risks and complications of this elective procedure and I understand that no guarantees are implied as to the outcome of the procedure. Please note this consent is valid for all future microneedling treatments (with/or without PRP) that I choose to receive from BLOOM HEALTH.
