Lisa Ledbetter, L.Ac.

3900 S. Wadsworth Blvd., Suite 400

Lakewood, CO 80235

303-934-3753

Consent Form for MicroNeedling

MicroNeedling is an elective procedure for cosmetic purposes only. I have had the opportunity to ask questions and understand the nature, goals, limitations and possible complications of this treatment. I have had the opportunity to discuss alternative forms of treatment and understand that results may vary.

I clearly understand and accept the following:

i. The goal of these treatments, as in any cosmetic procedure, is improvement - not perfection. I understand my results might not be perfect, and the number of treatments necessary may vary.

ii. There may be more treatments necessary than I anticipated.

iii. There is no guarantee that expected or anticipated results will be achieved.

iv. I understand that compliance with recommended aftercare guidelines are crucial for healing and prevention of scarring or skin textural changes.

MicroNeedling has a low risk of complications. Since this is a new technology, side effects may be seen as additional patients are treated. I understand the following side effects or complications may occur:

i. Discomfort at the treatment site with transient redness and swelling which may last up to two hours or longer. The redness may last up to 2-3 days. The treated area may feel like a sunburn for a few hours after treatment.

ii. Increased or decreased pigmentation is possible and can take 3 to 6 months or more to resolve.

iii. Loss of pigmented lesions such as freckles may give the appearance of loss of pigment.

iv. Small areas of scabbing may occur 2-3 days following the treatment.

v. There is a possibility of bruising (hematomas), puffiness, blood, tingling, itching, warmth, pain or other symptoms during and after treatment.

vi. It is possible, though very unusual, that you may have problems with bleeding during a MicroNeedling treatment. Should post MicroNeedling bleeding occur, it will usually only consist of a few drops. Accumulations of blood under the skin may cause a bruise, or hematoma, which will resolve itself.

vii. Infection is possible if proper aftercare guidelines are not followed. Should an infection occur, additional treatment, including antibiotics, may be necessary.

Contraindications

While MicroNeedling treatments are safe and effective for most women and men, there are some people who will not be good candidates for these types of treatments. Here is a general contraindication list that should be considered by anyone who is thinking of undergoing MicroNeedling:

▪ Pregnancy – if you are pregnant or nursing you are advised to not receive any MicroNeedling treatments. To date there have been no studies conducted to see what effects these treatments may have on the unborn child, but as a general rule, pregnant women should stay away from any type of cosmetic/elective procedures.

▪ Diabetes - unstable diabetes patients should not be treated due to problems with healing.

▪ Accutane or any related acne medication - Accutane or any related drug should be discontinued for a minimum of 6 months prior to undergoing MicroNeedling.

▪ Active Herpes Simplex in the treatment area - treatment is possible once the outbreak is healed, however it may be advisable to take prescription strength antiviral medication to keep this condition in remission during the treatment series.

▪ Dry skin - if your skin is overly dry, you will need to start moisturizing and ensure the condition is under control prior to undergoing any treatment.

▪ Any active inflammatory skin condition e.g. eczema, psoriasis, infection, rash or any type of dermatitis at the treatment site (because it may aggravate the condition).

____ I have no allergies to anything that I am aware of.

____ I understand that I must verbally inform my acupuncturist of any concerns, use of medication (including aspirin or other pain medications) or medical conditions I have before receiving MicroNeedling procedures even though it is noted on the medical history form.

____ I understand that if I do have a medical condition or any allergies that would contraindicate the MicroNeedling procedure, the acupuncturist can make a decision to ensure my safety and refuse doing any MicroNeedling procedures on my behalf.

____ I am not under the influence of alcohol, drugs or any other substances.

____ I release ProCell Therapies, and its subsidiaries and representatives of all claims for injury seen or unseen that may occur as a result of this procedure.

____ I understand that no promise has been made to me as to the final result of the procedure I have consented to undergo.

____ There are possible risks involved, and these have been explained to me prior to having the treatment and I understand them.

____ I have been given the opportunity to address all of my questions and concerns about the risks, hazards and aftercare for the procedure(s) that will be performed with my consent.

____ Although noticeable results may be obtained with a single MicroNeedling treatment; the greatest improvement will be seen after a series of four to six consecutive procedures.

I hereby release ProCell Therapies as well as my treatment provider Lisa Ledbetter from any liability associated with my MicroNeedling treatment. I grant ProCell Therapies and my treatment provider the right to use any photographs, testimonials, or other information that I knowingly provide for promotional purposes.

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