Microneedling Consent Form

Treatment with hyaluronic acid and other injectable dermal fillers can help smooth out folds and wrinkles, add volume to the cheeks, temple, lips, and contour facial features that have lost their fullness due to aging, sun exposure, illness, etc. In healthy individuals without autoimmune issues or infections, HA fillers and other injectable dermal fillers can be performed with minimal to no complications in most cases, however, I have reviewed risks and consent to treatment.

Risks and Complications include but are not limited to the following. Please check each box indicating acknowledgement:

  • Facial Bruising, redness, swelling, itching and pain. These symptoms are usually mild and last less than a week but can last longer. Patients who are using medications that can prolong bleeding, such as aspirin, Warfarin, or certain vitamins and supplements, may experience increased bruising or bleeding at the injection site.
  • Nodules and palpable material. You may be able to feel the filler material in the area where the material has been injected. Any foreign material injected into the body may create the possibility of swelling or other local reactions to a filler material.
  • Migration. Filler may move from the place where it was injected.
  • Infection. All transcutaneous procedures carry the risk of infection.
  • History of Herpes Infection. Filler carries the risk of a recurrence of an outbreak of herpes and that outbreak could be severe in nature.
  • Allergic Reactions.
  • Keloids/Scarring. Known susceptibility to keloid formation or hypertrophic scarring has not been studied.
  • Accidental Injection into a blood vessel. Filler can accidentally be injected into a blood vessel, which may block the blood vessel and cause local tissue damage or potentially even a heart attack, stroke, or blindness.
  • Duration of Effect. The outcome of treatment will vary among patients. In some instances, additional treatments may be necessary to achieve desired outcomes.
  • Concomitant Dermal Therapies. I understand that the safety of dermal fillers with concomitant dermal therapies such as epilation, UV radiation, laser, mechanical or chemical peeling procedures, massage, use of clarisonic skin cleansing brush has not been evaluated in controlled clinical trials. The use of any of these procedures is not recommended as such treatments may alter the characteristics of the filler for 2 weeks following this treatment.
  • It is not recommended that you have dermal fillers injected if you are nursing or pregnant.
  • Sun Exposure. Sun exposure should be minimized for approximately 24 hours after treatment or until any initial swelling or redness goes away.
  • There are very rare times where people can develop delayed swelling or a delayed inflammatory nodule that seems to be triggered by some sort of immune system stimulation like an infection somewhere in the body or even after a vaccination.
  • authorize the taking of clinical photographs for purposes of documentation of treatment. I understand that refusal of photos will result in not having treatments performed.

Please check each box as acknowledgement of each statement:

  • I am not pregnant or trying to become pregnant nor am I breastfeeding
  • I do not have any major illnesses, including Auto-immune issues or active cancer
  • I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine or bee stings.
  • I am in an optimal state of health and have not been ill for the past 4 weeks.
  • I have not received any recent vaccines in the past two weeks.
  • I am not traveling outside of the country in the next 7 days.
  • I have not recently, nor am I planning any dental procedures in the next 4 weeks.
  • I am being honest and truthful about my medical history including sharing any past facial surgeries and previous injections.

Cost/Fees Payment for this cosmetic procedure is my responsibility. I understand that there will be an additional fee for touch ups. I understand that this is an "elective" procedure and I am undergoing treatment of my own free will. Payment is my full responsibility regardless of outcome and is due at the time of my treatment. I understand that there are no refunds for such elective treatments. I accept responsibility for any complications that may occur and thereby absolve Medfit of Georgia or any associated person of any blame resulting there from. In agreeing to such, I also agree to no credit card chargebacks given the elective nature of my treatments. I understand that there is no guarantee of any particular results of any treatment. I also understand that follow-up treatments with additional fillers may be necessary to achieve full correction and this is at an additional fee. I am aware that the duration of treatment is dependent on many factors. I will report any concerns including abnormal swelling, pain, color changes, or lumps to my provider.

I hereby voluntarily consent to treatment. The procedure(s) has been explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure. I certify that if I have any changes occur in my medical history, I will notify the office. By signing below, I acknowledge that I have read the foregoing informed consent, have had the opportunity to discuss any questions that I have with my provider to my satisfaction, and consent to the treatment described above with its associated risks. I hereby release the Medfit of Georgia and any associate there of from liability associated with this procedure. This consent form is valid until all or part is revoked by me in writing. This consent is valid for all future filler injections in the future as well.

Please enable JavaScript in your browser to complete this form.

I hereby authorize MedFit Of GA or any delegated associates to perform Microneedling Therapy (Collagen Induction Therapy). I understand that this procedure is purely elective.

What to Expect:

- Depending on the area of your face or body being treated and the type of device used (i.e. needle length), the procedure is well-tolerated and in some - cases virtually painless, feeling only a mild prickling sensation.
- Your practitioner will apply a topical anesthetic to your skin prior to treatment to reduce any pain and discomfort.
- Your skin will be pink or red in appearance, much like a sunburn, for a few hours to days following treatment.
- Minor bleeding and bruising is possible depending on the length of the needle used and the number of times it is pressed across the treatment area.
- Your skin may feel warm, tight, and itchy for a short while. This should subside in 12-48 hours.

Possible Side-Effects:

- Side effects or risks are minimal with this type of treatment and typically include minor flaking or dryness of the skin with scab formation in rare cases.
- Milia (small white bumps) may form; these can be removed by the practitioner.
- Hyper-pigmentation (darkening of certain areas of the skin) can occur very rarely and usually resolves after a month.
- If you have a history of cold sores, this procedure may cause flare ups.
- Temporary redness and mild-sunburn effects may last up to 4 days.
- Freckles may temporarily lighten or permanently disappear in treated areas.
- Other potential risks include: crusting, itching, discomfort, bruising, infection, swelling, and failure to achieve the desired result. Permanent scarring (less than 1%) is extremely rare.

The benefits and risks of the procedure have been explained to me, and I accept these benefits and risks. The nature of my medical or cosmetic condition has been explained to my satisfaction as have been any substantial or significant risks of harm. I am also aware of and accept the risk of rare and unforeseen complications which may not have been discussed and which may result from this treatment.

I have had the opportunity to ask questions and seek clarification of this procedure and its alternatives including no treatment and my questions have been answered satisfactorily.

I understand the following contraindications listed below and will notify my provider if any of the following apply to me:

- Active infections - viral, fungal, bacterial
- Rashes, warts, skin cancer
- Active acne
- Immune-suppressed patients
- Skin-related autoimmune disorders
- Pregnant or breast-feeding
- Patients on anticoagulants (NSAIDS, ASA, Coumadin/Warfarin)
- Recent ablative dermal procedure
- Rosacea
- Diabetes
- Actinic (solar) keratosis
- Keloids

Patient Information

Patient's Name
Clear Signature
Date of Consent


Please enable JavaScript in your browser to complete this form.
What Services Are You Interested In
Help us stop spam by solving the math problem.