Potenza RF Microneedling Consent

I consent to have my pictures and/or videos taken and stored in the electronic medical record system of Skyn Aura. Such photographs and videos will not be used for any purpose except internal training without my express permission. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment prior to receiving services. I further agree in the event of non-payment, cancellation of payment, or any payment issues, to bear the cost of collection, and/or the court cost and legal fees, should those be required. I consent to email, text and phone communications related to post-procedure care and follow-up appointments. I consent to receive promotional messages and marketing messages via email, phone and sms messages from Skyn Aura. I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing/breastfeeding). I do not have or have not had any major illnesses which would prohibit me from receiving this treatment. I have not had any dental procedures or vaccinations in the last 14 days. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to, lidocaine. I am completely of sound mind and am fully aware of all the risks and possible complications of this procedure. I attest that I have not consumed any alcohol or other substance within the last 12 hours that would hinder my ability to consent to the procedure(s). I understand this procedure is one hundred percent voluntary. I acknowledge that no guarantee has been given regarding the results that may be obtained. I have read the material given to me and I am fully satisfied that all of my questions and concerns have been addressed. I understand that I am required to attend post-procedure check-ups as advised by Skyn Aura and that I am required to follow all post-treatment instructions. I have received and fully understand the pre- and post-treatment instructions. I have advised my provider of my medical history including all previous medical conditions and medications currently being taken by me. Alternatives to the procedures and options that I am choosing to get today have been fully explained to me. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications and injury. I am aware that there may be other risks or complications not discussed that may occur. I also understand that during the course of the proposed procedure, unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed. I have the right to refuse any particular exam, test, treatment or other intervention, with the understanding that doing so may affect the Practice’s ability to provide my care. I understand that appropriately supervised students, residents, and/or trainees may observe and assist in my care unless I expressly object. I understand that the Practice providers and staff treat all patients with dignity and respect, and the same is expected in return. There is a zero-tolerance policy for inappropriate, discriminatory, and/or threatening behavior.I acknowledge that no guarantees or promises have been made to me concerning the results of this procedure or any treatment that may be required as a result of this procedure. I understand there are no refunds and that multiple treatments are often required to achieve noticeable and lasting outcomes. I also understand that promotional items have no refund value. By accepting and signing, I acknowledge that I have read this informed consent, I understand it, and I agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent treatments with the above understood. I hereby release the Medical Director(s), the Skyn Aura provider performing the treatment and Skyn Aura from liability associated with this procedure. I have been given the opportunity to ask questions and my questions have been answered to my satisfaction.I authorize the provider at Skyn Aura to perform Radio Frequency Microneedling treatments on me. I understand that these results are not permanent but will achieve a significant reduction. Microneedle radiofrequency involves insertion of fine electrodes mechanically into the skin followed by the discharge of a small amount of radio frequency energy at the desired depth. This leads to stimulation of new collagen production and restructuring of old collagen bundles in the skin. Multiple sessions may be required based on the severity of the skin condition. Skin may continue to improve till 3 months – 6 months after a treatment. Even after multiple sessions, the complete eradication of the skin problem may not happen and maintenance sessions may be required for maintaining the improvement. Strict sun protection is advised for a few days after the procedure to avoid any adverse effects of the treatment. I understand that there is a rare possibility of side effects or serious complications including but not limited to permanent discoloration, burns, or scarring. I am aware that careful adherence to all advised instructions will help reduce the possibility of side effects. During the procedure and shortly after, I understand that I might experience an itching sensation which may vary in degree based on hair density, area sensitivity and which treatment head is used. A mild sunburn sensation may follow for typically up to one hour and will be reduced with the application of cooling and soothing creams. There is a possibility of rash, the severity and duration of which depend on the intensity of the treatment and the sensitivity of the area to be treated. Micro-crusting may occur over some areas with very dense and coarse hair, and may take 5-10 days to flake off. It is important not to manipulate or pick, which may otherwise lead to scarring. Bruising may rarely occur and may last several days. I will disclose any new changes in medication and/or changes in medical history every time I receive a treatment. I understand that sun exposure or tanning of any sort is a risk for Radio Frequency Microneedling Procedures and may increase the chance of short term or long term complications. The procedure as well as potential benefits and risks have been thoroughly explained to me and all of my questions have been answered. Pre and post-care instructions have been discussed and are clear to me.

ARBITRATION AGREEMENT – READ CAREFULLY

It is understood and agreed by Skyn Aura and , as a recipient of services, that any legal dispute, controversy, demand or claim that arises out of or relates to the services provided to me by Skyn Aura or any other service provided by Skyn Aura to me shall be resolved exclusively by binding arbitration as provided by California law. It is understood that any dispute as to medical malpractice (whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompletely rendered) will be determined by submission to arbitration and not in a court of law or before a jury. It is in the intent of the parties that this agreement cover all existing or subsequent claims or controversies, whether in tort, contract, or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to the treatment of services provided or not provided by any employee, physician, association, partner, or agent affiliated with Skyn Aura to a patient.  This party includes causes of action that might be brought on behalf of me by a spouse, heir, child (born or unborn), guardian or parent. I read, write and fully understand English. I am of sound mind and body and have the full capacity to consent to this treatment. I hereby consent to the Radio Frequency Microneedling Procedures and hereby authorize the Skyn Aura provider to perform the Radio Frequency Microneedling Procedure.