Microneedling Treatment Consent

This consent form confirms that I have been satisfactorily informed and educated about microneedling treatment, including its purpose, expected benefits, limitations, risks, alternatives, possible adverse effects, and post-care responsibilities. This information allows me to make a voluntary and informed decision regarding whether to proceed with this procedure.

Nature of Microneedling

I understand that microneedling is a skin rejuvenation procedure that uses a device with multiple fine needles to create controlled microchannels in the skin. This process, also known as collagen induction therapy, stimulates the skin’s natural healing response and promotes the production of collagen and elastin.

I understand that the use of adjunctive treatments such as skin boosters, growth factors, exosomes, or platelet-rich plasma may enhance results compared to microneedling alone.

Expected Results & Treatment Course

I understand that results are not immediate and that skin changes occur gradually as collagen stimulation progresses. Optimal results are typically seen after approximately 2–3 months.

I understand that although improvement may be noticeable after the first treatment, multiple sessions may be required to achieve desired outcomes, depending on skin condition severity and individual response.

I understand that maintenance treatments may be necessary due to natural aging and ongoing collagen degradation over time.

Treatment Variability & No Guarantee

I understand that individual results vary and that it is not possible to predict how I will respond to treatment or how many sessions may be required. Some patients experience significant improvement, while others may experience minimal or no improvement.

I understand that although positive results are expected, medicine is not an exact science, and no guarantee or assurance can be made regarding the outcome of treatment.

Alternatives

I understand that alternatives to microneedling exist and may include other aesthetic treatments or no treatment at all. These alternatives have been discussed with my provider.

Medical History & Disclosure

I agree to disclose all current medical conditions, allergies, and medications prior to treatment.

I understand that microneedling and similar procedures may trigger cold sore or herpes simplex outbreaks, and I have informed my provider if applicable and requested prophylactic medication when appropriate.

I deny active or untreated skin conditions including, but not limited to, skin cancer, papulopustular rosacea, moderate to severe acne, herpes simplex, warts, scleroderma, bacterial or fungal infections, open lesions, or solar keratosis.

I deny significant medical conditions including cardiac disease, autoimmune disorders, blood or platelet disorders, liver disease, HIV, diabetes, systemic cancer, chemotherapy, steroid therapy, or anticoagulation therapy.

I deny that I am currently pregnant, attempting to become pregnant, or breastfeeding. I understand that the safety of microneedling during pregnancy and breastfeeding has not been established. If uncertain, I will request pregnancy testing prior to treatment.

Risks & Possible Complications

I understand that microneedling involves risks, which may include but are not limited to discomfort, swelling, tenderness, redness, petechiae, pigment changes, blistering, crusting, scabbing, flaking, milia, pustules, infection, scarring, increased skin sensitivity, allergic reactions, and delayed wound healing.

I understand that pigment changes are usually temporary but may rarely be permanent.

I understand that infections are rare but possible and may require medical treatment, and that immunosuppressed individuals may have an increased risk.

I understand that unknown or unforeseen side effects may also occur.

Delayed Reactions & Patient Responsibility

I understand that patient experiences vary and that delayed reactions may occur. I agree to notify AI Wellness Center of Excellence promptly if I experience any unusual, worsening, or concerning symptoms.

Pre- and Post-Treatment Instructions

I understand that the procedure, including its benefits, risks, alternatives, and possible complications, has been explained to me.

I acknowledge that I have received counseling regarding pre- and post-treatment care and agree to follow all instructions provided.

Provider Authorization

I authorize Dr. Gideon Kwok, D.O., and/or trained and qualified medical associates at AI Wellness Center of Excellence to perform microneedling procedures on me.

I acknowledge that I have had the opportunity to inquire about the qualifications and experience of the provider administering my treatment and that I am satisfied.

Voluntary Consent

I confirm that my consent is voluntary, informed, and freely given, and that I agree to notify the clinic of any changes in my medical history or concerns related to treatment.

Final Acknowledgment

I certify that I have read, understood, and agree to the contents of this Microneedling Treatment Consent. This document supersedes all prior verbal or written disclosures, and I freely consent to microneedling procedures.