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CONSENT FOR TREATMENT: Micro-needling (Skin-pen) Consent
Sign our consent form:
If the cancellation occurs within 14 days of the course date, a $100 cancellation fee will apply. This policy is in place to ensure the smooth operation of our courses, as last-minute cancellations can potentially impact the live injection experience for a student if the spots can't be filled.
DESCRIPTION OF THE PROCEDURE
The Skin Pen 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 yet does not pose the risk of permanent scarring. 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.
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. This will diminish greatly after a few hours following treatments and within the next 24 hours the skin will be completely healed. After 3 days most visible erythema will be resolved.
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. Not recommended for women who are pregnant or nursing.
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 Micro pen 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.
By registering, paying and attending the AESTRA Institute course, you understand that you may be photographed, filmed or videotaped and you expressly give the AESTRA Institute, its owners, agents and principals the right to take pictures and/or recordings of you and use your likeness, image, photo without compensation, for broadcast, display, and exhibition in any medium for purposes of advertisement and education and to put the finished pictures /recordings to any use without limitation. You further expressly release AESTRA Institute from any or all claims or actions arising out of or resulting from any use of your image. However, the AESTRA Institute shall not be obligated to use your image.
***By consenting to this treatment, I agree, affirm and represent that I am waiving my right to seek any recovery for any damages that occur as a result of receiving this treatment whether such damages are as the result of an inherent risk or latent or unintended risk including any damages that may occur which are not the result of a known or expected risk. I waive any and all recovery for damages of any kind whatsoever.***
I have been informed and I understand that the practitioners who will perform this procedure may or may not be licensed to practice in the state of Florida. I have been informed and understand that Aestra Institute and Denise Merdich have not reviewed or investigated whether the practitioners performing this procedure have appropriate licensure within the state of Florida. Despite knowing that the practitioner(s) performing my procedure may or may not be licensed in Florida, I am voluntarily giving consent for the practitioners who may be licensed in other states to practice medicine, nursing, advanced registered nurse practitioners and physician's assistants to perform the procedure on me.
Thank you for your consent!