Fractional Laser / RF Microneedling Skin Rejuvenation consent form
The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your practitioner. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your practitioner prior to signing the consent form.
THE TREATMENT
Fractional Laser / RF Microneedling treatment is changing how people now perceive the visible effects of ageing (wrinkles) as well as the most common scarring (facial/acne) and stretch mark prone areas of the skin, with dramatic rejuvenation and skin resurfacing results. Minute sections of the skin are targeted with laser light, which penetrate into the tissue, causing small columns of thermal damage to stimulate significant collagen renewal. The surrounding non-affected areas of skin aid the body’s natural recovery process, for dramatic results without significant downtime. A wide variety of skin conditions can be treated with Fractional Laser / RF Microneedling, but it is most commonly used: • Stretch Marks - unrivalled post-pregnancy & exercise-induced stretch marks solution with profound results; the perfect alternative to long-term topical agents. • Fine Lines & Wrinkles - the appearance of fine lines and wrinkles are reduced through stimulation of collagen production, plumping the skin and resulting in a natural youthful appearance. • Scarring - dramatically smoothing and improving commonly scarred areas of the skin; providing excellent results on facial acne scarring. • Dramatic Rejuvenation - minimising pigmentation and age spots as well as giving the skin a fresh and glowing appearance. • Resurfacing & Congestion - helping tackle general congestion ‘lumps and bumps’ on the skin, resulting in a smooth and clear complexion.
Treatment is suitable for most people and highly recommended for individuals wanting a brighter, more even skin tone, smoother skin texture with improved skin elasticity, a reduction of wrinkles, reduced pore size and improvement to scars (including acne scars) and stretch marks. The skin is cleansed and the handpiece is moved over the skin delivering tiny microscopic laser beams. Typically treatment time varies depending upon the skin condition and the area being treated, but will range from 10 to 40 minutes. After treatment the skin is cooled. Protective eye wear must/may be worn during treatment. You will experience a mild sunburnt sensation for a few hours after treatment and the skin may be red for 1 to 2 days. This is a normal sign that the skin is healing at a deep level. Swelling is likely but minimal, and resolves in 2 to 3 days. As the healing process occurs, your skin may have a ‘bronzed’ appearance that lasts from 3 to 10 days, depending on the treatment level. Your skin may naturally exfoliate and may flake as if you had mild sunburn. Improvement is evident after the first session, but for optimum results 3 to 5 treatment sessions are often advised. Treatment is carried out every 2 to 6 weeks, depending upon the level of rejuvenation required. Changes to the collagen structure are not immediate and best results are often visible several months after treatment
I understand that a test patch must be carried out a minimum of 24 hours prior to treatment. This test patch will only be valid for 6 months and further test patches may be carried out throughout the course of treatment when settings are being assessed to achieve the best results. I have informed the practitioner of any recent sun exposure, including the use of sun beds and fake tan and will continue to do so thought my course of treatment. I understand that I must wear protective goggles throughout this procedure.
RISKS AND COMPLICATIONS
I have been advised that the goal of the procedure I have requested is improvement in the appearance, not perfection, that there is a possibility that imperfections might ensue, and that the results may not meet my expectations or the goals that have been established. In relations to this I know that the practice of medicine and surgery is not an exact science and that, therefore, no guarantee or assurance has been made by anyone regarding the procedure, which I have herein requested, and autorised. Although good results are expected, there is no guarantee or warranty expressed or implied on the results that may be obtained. Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. It has been explained to me 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: • Pain – It can be uncomfortable at the time of treatment and for a variable time after – painkillers can be taken in the first 24 hours to relieve discomfort. • Swelling, Redness or Bruising – This is a normal response and usually settles after 2-3 days. The treated area may also ooze a little. • There is a risk of scarring. • Blistering – the area must be left to heal naturally. If blisters burst then a non adherent dressing may be applied. • Infection – This is very uncommon, and results in increased pain and formation of pus. Antiseptic or antibiotic therapy may be required. • Pigment changes. Both hypo pigmentation (lightening of he skin) and hyper pigmentation (darkening of the skin). Both generally last a few months but can be longer. • Some textural changes can occur.
I understand that sun exposure, fake tan or sun beds are not advised during my treatment programme as this may result in pigment changes or markings on my skin that may not fade. Use of sunblock or SPF 50+ is recommended. I have been recommended to use skin moisturiser 2-3 times daily to hydrate and smooth irritation. I understand the use of any other products is not advised. I have been advised that cooling the area can improve your comfort and reduce post treatment swelling and redness. I have been advised that hot baths/ showers or any other heat treatments should be avoided for a minimum of 24 hours. I have been advised to keep the area clean and dry and to always allow scabs to heal naturally.
RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue treatment at any time.
Photographs and videos will be used for scientific and marketing purposes both in publications and presentations. Photographs and video may be taken of me for educational and marketing purposes. I hold the clinic harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.
RESULTS
Most patients are pleased with the results of the treatment use. However, like any aesthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that you will not require additional treatment to achieve the results you seek. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue conditions, my general health and life style conditions, and sun exposure. I have been instructed in and understand the post-treatment instructions. I understand this is an elective procedure and I hereby voluntarily consent to treatment. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-procedure questions or concerns to the treating clinician. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English.
PAYMENT
The procedure cost includes the professional fee for the injections, follow up visits to monitor the effectiveness of the treatment, and the cost of the material itself. Additional costs of medical treatment would be your responsibility should complications develop from injections.
I hereby authorise my practitioner to administer the treatment and agree to hold him free and harmless from any claims, refunds or suits damages for any injury or complications whatsoever which may result in the treatment.
I understand that my treatments require payment at the time of service and the prices and fee structure for treatments have been explained to me.
There are no refunds on treatments or on treatments paid for in advance.
Tap or click on the signature above to sign
You should note that if the practitioner is unable to explain to you the contraindications or is unsure of anything that may apply to a specific condition then they should not treat you without asking you to consult with your GP or consultant.
It is your responsibility and not that of the therapist to consult your GP or consultant. By signing this form you are hereby indemnifying the therapist against any adverse reaction sustained as a result of the treatment.
Data Protection and Privacy
We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.
