Advanced Hair Restoration Microneedling Consent Form
Product/Treatment information:
The Advanced Hair Restoration Microneedling treatment is an in-clinic procedure that uses a unique blend of proteins and growth factors derived from umbilical cord lining and combined with scalp microneedling for follicular activation. Advanced Hair Restoration Treatments activate dormant hair follicles, encouraging them to regenerate and produce healthy, strong hair strands. Through this process, you can experience natural and long-lasting hair regrowth without requiring invasive surgeries or harmful chemicals. Of course, it should be said that we cannot guarantee you will end up with a full head of hair, but it is the best non-surgical option with a solid evidence base behind it. Combined with our in-clinic Skinpen Precision delivery, you truly will receive the least invasive, best non-surgical option for hair loss, damaged hair, and thinning hair.
You will require a minimum of six treatments, with each treatment spaced one week apart.
The Advanced Hair Restoration Microneedling treatment involves an automated microneedling pen and the infusion of Calecim cord-lining stem-cell solution.
We will cleanse your hair with an anti-microbial cleanser directly before treating your scalp.
Your practitioner will apply a layer of Calecim stem cell-conditioned solution to glide the device across your scalp. Hundreds of micro-channels are created with each pass across the skin and blood perfusion increases.
It is normal for the scalp to have a sunburn appearance and pinprick bleeding; it is a necessary endpoint to stimulate the healing cascade effectively.
Following microneedling, the remaining calecim hair solution will be applied to your scalp and massaged.
Alternative Treatments
Your practitioner will always advise you of the safest and most effective treatment based on your medical history and needs. However, you should also consider the option of no treatment at all. Alternatively, other treatment options are available to encourage hair growth and include medications and hair transplants. You may also wish to consider a wig system. Although we do not provide these treatments, please discuss these options with your practitioner if you wish to explore alternative options.
There are some reasons why you cannot receive Advanced Hair Restoration Microneedling.
Contraindications:
You cannot have Advanced Hair Restoration Microneedling treatments if:
You have had roaccutane/Isotretinoin medication in the last six months.
You have an active infection or inflammation near the intended treatment area.
You have a history of keloid or raised scarring.
You have active eczema and /or psoriasis on your scalp.
You have actinic (solar) keratosis in the intended treatment area.
You have uncontrolled diabetes or poor wound healing.
You have raised moles, warts or any raised lesions in the intended treatment area.
You have scleroderma, collagen vascular diseases or cardiac abnormalities
You have blood clotting problems or are taking blood thinning medications.
You are immunosuppressed.
You have scars less than six months old in the intended treatment area
You think you could be pregnant, are pregnant, or are lactating or breastfeeding.
Cautions:
You need to tell your aesthetic practitioner if:
You suffer from recurrent bouts of herpes simplex infections, as any microneedling treatment may encourage an outbreak.
Material Risk (the level of significance you personally apply to the risks, side effects or complications of this treatment within your own circumstances):
As with any medical procedure, this treatment carries the risk of side effects or complications. Discuss these risks with your practitioner to fully comprehend their implications. Consider the risks in relation to your personal circumstances, including your health, lifestyle and career and decide if they are acceptable. If not, discuss alternatives or take more time to decide.
Associated Risks:
Scalp redness. Scalp erythema (skin redness) is the most common and likely side effect of your treatment with microneedling. This is a positive side effect that is a part of your skin healing response. This will usually last for up to three days.
Dry, flaking scalp. This usually occurs two to three days post-treatment and lasts up to ten days. It is where your upper scalp skin cells are shedding, and new healthy scalp skin cells are generated in their place.
Treatment site bruising, discomfort, mild swelling. These symptoms are usually mild and last less than a few days but can last longer. Patients 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.
Temporary Hair loss. Although this may seem worrisome, you may lose some existing hair as part of the renewal process and regrowth of new hair strands. Most people will not notice this, but may be more extreme for others. It is not thought to be a permanent hair loss.
Herpes (cold sores) re-activation. Treatments that stimulate a skin response, such as microneedling, carry the risk of an outbreak of herpes (fever blisters/cold sores/shingles) in individuals who already carry the herpes virus. You should manage this as you would normally, such as by using over-the-counter cold sore medication. Please contact your practitioner if you experience a severe outbreak following treatment.
Infection. As with any procedure that involves a break to the skin’s surface, a microneedling treatment carries the risk of infection, although rare. You should inform your practitioner if swelling, heat and/or discomfort occurs in the treated area for longer than a few days. This may require medical intervention, such as antibiotic therapy.
Hyperpigmentation. Although microneedling is used to reduce skin pigmentation, post-inflammatory hyperpigmentation can occur in certain individuals, including following a scalp microneedling treatment.
Hypersensitivity/Allergy/Anaphylaxis. Allergic reactions or anaphylactic shock may occur with any product applied to the skin, including scalp sterilisation products and Calecim Advanced Hair System solution.
Scarring. There is a very small risk that the areas treated may cause scarring or skin marking, which could be temporary or permanent.
Dissatisfaction. Very rarely, scalp microneedling may have little to no effect on hair growth. The treatment relies upon a biological response; therefore, hair regrowth cannot be guaranteed. There will not be any refunds provided in any case.
This consent form is not meant to include all possible risks associated with Advanced Hair Restoration Microneedling, as known and unknown side effects and complications are associated with any medical treatment. We have written this consent form to ensure you are fully informed of the procedure, reasons why you may not be able to receive treatment, and known risks of Advanced Hair Restoration Microneedling.
Photographs:
We need to take photos of the treatment area to document the original condition before treatment begins and to monitor results and potential changes throughout the treatment process. These photos will become part of your medical aesthetic treatment record at Lumiere Medispa.
You have the right to refuse consent for these photographs. However, please be aware that without this consent, we will not be able to treat you for medico-legal reasons.
If we wish to use your photos for any other purpose, we will always seek separate written consent from you. You have the right to refuse this additional use of your photos, and it is not mandatory to consent to any other photo usage to receive treatment.
By signing this consent form, you acknowledge and confirm the following:
Risks and complications
You have discussed the potential risks and benefits of Advanced Hair Restoration Microneedling with your practitioner, and your questions have been answered satisfactorily.
You understand that medical attention may be required to resolve any complications associated with your treatment. In most cases, except those in an emergency, you should contact your practitioner for advice/treatment.
Medical History
To the best of your knowledge, you have provided the details of your past medical history and will inform your practitioner if this changes before any future treatments.
You understand that withholding aspects of your medical history could lead to serious physical and mental harm.
Contraindications & Cautions
You are not pregnant or possibly pregnant, lactating or nursing, and you will inform your practitioner if this changes before any future treatments.
Fees & Charges
You understand and agree that all services rendered will be charged directly to you, and you are personally responsible for payment.
You further agree, in the event of non-payment, to bear the cost of collection, court costs and reasonable legal fees, should they be required.
Refunds
Fees charged for treatment are for the delivery of a treatment and the accompanying service, which is inclusive of the following;
-Consultation and assessment
-The provision of information and advice
-The provision of the treatment itself, as described above
-Follow-up appointments and aftercare advice and support as appropriate
Whilst we undertake to provide excellent service, factual, honest and ethical advice, safe, expert treatment in experienced hands and only the best products, we cannot guarantee your results. We cannot offer refunds if the results achieved fail to meet your expectations. The successful outcome varies by degree, and how long these effects last varies from one individual to another and cannot be guaranteed.
You understand that whilst you have been advised of a probable result, this should not be interpreted as a guarantee.
You will contact your practitioner if you are unsatisfied with your treatment outcomes.
Aftercare
You have verbally discussed the aftercare required following Advanced Hair Restoration Microneedling and have been informed that you will also receive this via email. You understand the importance of following the post-treatment advice and agree to follow it.
You understand that failure to follow this advice could lead to serious physical and mental harm.
Photograph Use Consent:
You understand that receiving treatment at Lumiere Medispa requires photographs to be taken of the treatment area. These photographs may be taken before, during, and after each treatment and will form part of your legal medical record at Lumiere Medispa. By signing below, you freely give your consent for your photos to be used solely for this medico-legal purpose. If we wish to use your photos for any other purpose, we will always seek separate written consent from you, and you have the right to refuse.
Valid Consent
By signing below, you acknowledge that you have read and understood this consent form and have had the opportunity to discuss any questions you have with your practitioner to your satisfaction. You consent to receive an Advanced Hair Restoration Microneedling treatment under the terms of this consent form and understand that you have the right not to consent to this treatment and that your consent is voluntary.
