Microneedling Consent Information with Additional Patient Consent for Treatment During COVID-19 Pandemic
I understand that I am opting for an elective medical consultation/treatment/procedure.
I understand that the novel coronavirus, the World Health Organization has declared COVID-19, a
worldwide pandemic and that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, social distancing is recommended.
This is not entirely possible with my proposed treatment, however, I am satisfied that safety measures are in place to minimise risk as much as possible, and patient contact will be kept to an absolute minimum in line with medical need.
I understand the Management and Clinical Staff are closely monitoring the COVID-19 situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19.
However, given the nature of the virus, I understand there is an inherent risk of becoming infected
with COVID-19 by virtue of proceeding with treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective consultation/medical treatment/procedure, and I give my express permission to proceed.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I understand that COVID-19 can cause additional health risks, some of which may not currently be known at this time, in addition to those risks associated with the medical consultation/ treatment/procedure itself.
I have been given the option to defer my medical consultation/treatment/procedure to a later date.
However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired medical treatment/procedure I confirm that I am not presenting with any of the following symptoms of COVOID-19 listed below:
• Shortness of Breath
• Loss of Sense of Taste or Smell
• Dry Cough
• Runny Nose
• Sore Throat
I understand that air travel significantly increases my risk of contracting and transmitting the COVID19 virus. I confirm that I have not travelled in the past 15 days.
I confirm that if I develop COVID-19 symptoms following my medical
consultation/treatment/procedure or a known contact of mine develops symptoms, I will
immediately inform the practitioner to enable appropriate measures to be put in place and contact
tracing to commence I confirm I have been informed that.
I understand that further lockdown may impact on managing complications and immunological reactions.
Microneedling is a corrective treatment that creates rejuvenating micro-channels into the skin's matrix. Employing patented technology, Microneedling oscillating action effortlessly glides over the skin to initiate and stimulate the body's own natural healing and regenerative response. It is possible to achieve striking results by delivering a versatile and customised treatment, which has been documented to improve the appearance of ageing, wrinkles, uneven skin tone, uneven texture, stretch marks and scar tissue on face and body areas. Microneelding treatments are fast, effective, comfortable and offer results after just one treatment. Based on your areas of concern, your practitioner may recommend a series of treatment for optimal results.
Not suitable for patients experiencing active
• Papulopustular rosacea
• Acne vulgaris stage III-IV
• Herpes simplex
• Bacterial/fungal infections
• Open lesions
• Solar keratosis
• Skin cancer
Certain health conditions, medications, supplements and lifestyle factors may affect a Microneedling procedure. If you are prone to herpes simplex (cold sores), it is recommended to take or apply a targeted prophylaxis, such as acyclovir, to prevent a possible outbreak.
Your practitioner will take all steps to ensure total comfort for your procedure. If at any point you feel discomfort, please inform your practitioner immediately. If you have any allergies or have had any past reaction to topical numbing cream or anesthetic, please inform your practitioner prior to treatment.
HEALTH & SAFETY:
Your treatment only uses sterile, single use consumables throughout the procedure, ensuring complete health and safety.
Please allow 45-90 minutes for your treatment including preparation, numbing and post-care.
During the skin healing process, minor itching, hives, flaking, or redness may appear. If symptoms persist, please call your practitioner. Do not pick, squeeze or agitate during the recovery period. Please avoid the following activities for up to 2 days following a DermapenTM clinical procedure:
• Direct ultra violet exposure (sun and solariums)
• Intensive cardio, exercise or gymnasium regimens
• Excessively hot showers, bathing, spas or sauna
• Spray or self-tanning
• Swimming in chlorinated pools or the ocean
• Tattooing (including cosmetic tattooing)
• Further clinical treatments (including, but not limited to): microdermabrasion, laser, intense pulsed light, chemical peels, muscle relaxant injections and dermal fillers) should be avoided for up to two weeks.
Please avoid the use of skin care products containing any of the following active resurfacing ingredients for up to 5 days following a clinical procedure:
• Alpha hydroxy acids (AHAs) (including but not limited to) glycolic, lactic or malic acid
• Beta hydroxy acid (BHA) including salicylic acid
• Benzoyl peroxide
• Retinoids (including but not limited to) tretinoin, retinol and retinaldehyde
• High levels of Kojic or azelaic acid
• Alcohol (including but not limited to) isopropyl alcohol/de-natured alcohol/rubbing alcohol
Post treatment care - use the products given to you by your practitioner for 5 days, maintain use of SPF factor 40 or above for t least 2 weeks.
I have completed this Consent Form honestly and to the best of my knowledge. Pre and Post-care and has thoroughly explained to me.