Microneedling Consent Form Description of the Procedure: The Eclipse Micropen skin needling system allows for controlled induction of the skin’s self-repair mechanism by creating micro “injuries” in the skin which triggers new collagen synthesis. The result is smoother, firmer and younger looking skin. Skin needling procedures are performed in a safe and precise manner with the use of the sterile Micropen needle head. The procedure is normally completed within 30-60 minutes depending on the required treatment and anatomical site. Side Effects: After the procedure, the skin will be red and flushed in appearance in a similar way to moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on the area being treated. The skin’s redness will diminish greatly after a few hours following the treatment and within the next 24 hours the skin will be generally calmed. After 3 days the skin will return to a normal or near normal appearance. Contraindications: Keloid scars; history of eczema, psoriasis and other chronic conditions; history of actinic (solar) keratosis; history of Herpes Simplex infections; history of diabetes; presence of raised moles, warts on targeted area. Absolute contraindications include; scleroderma, collagen vascular diseases or cardiac abnormalities; Blood clotting problems; active bacterial or fungal infection; immuno-suppression; scars less than 6 months old. Not recommended for women who are pregnant or nursing. Patient Consent: I understand that results will vary between individuals. I understand that although I may see a change after my first treatment; I may require a series of sessions to obtain my desired outcome. The procedure and side effects have been explained to me including alternative methods; as have the advantages and disadvantages. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that the Micropen treatment is not permanent as natural degradation will occur over time. I state that I have read (or it has been read to me) and I understand this consent and I understand the information contained in it. I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner. Print Name*Signature*THIS CONSENT FORM IS VALID UNTIL ALL OR PART IS REVOKED BY ME IN WRITING.Date* Date Format: MM slash DD slash YYYY Clinic Name*CAPTCHANameThis field is for validation purposes and should be left unchanged.