Skinko E Mesotherapy Consent Form
Product Treatment Information:
Viscoderm Skinko E is an anti-ageing and antioxidant complex containing more than 50 dermofunctional elements, including non-cross-linked hyaluronic acid, minerals, amino acids and vitamins. It is used to supplement the nutritional content of the extracellular matrix that surrounds the skin cells with the aim of:
Protecting and repairing skin damage caused by UV rays
Softening wrinkles and expression lines
Restoring skin tone, hydration, firmness and elasticity
A collection of very fine needles (Turtle Pin) or a single small needle is attached to a syringe and is used to deliver a mix of vitamins, minerals, and amino acids, providing the skin with the optimal amount of nutrition to function at its best. The stimulating effects of the needles will also stimulate the body's natural healing powers to create new healthy collagen and elastin fibres in the area.
For best results, you will need four treatments spaced three weeks apart. To maintain the result, it is advised to repeat the course every six months.
Treatment
For your comfort, a topical anaesthetic cream will be applied 30 minutes before the treatment. If you do not arrive 30 minutes before the appointment, you will have less time for the anaesthetic and may experience increased discomfort.
Your practitioner will thoroughly cleanse your skin and begin the procedure, which involves multiple tiny needles entering the skin, a small injection of the Skino-E solution, and withdrawal from the skin. This takes place multiple times over the entire intended treatment area.
It is usual for the skin to have a sunburn appearance and pinprick bleeding, and it is a necessary endpoint to deliver the product and effectively stimulate the healing cascade.
After the procedure, a Calecim Professional Recovery Complex layer will be applied as a hydrogel wound dressing. It is advisable to purchase this product during your first appointment for use at home throughout your treatment.
Your post-treatment care is very important; your practitioner will discuss this with you. An email of instructions will also be sent to the email address you provided.
Alternative Treatments
We want to inform you that you always have options, including no treatment at all. Other treatments to treat fine lines and wrinkles, such as thinning skin, skin brightening, and pigmentation, are available and may be discussed with your practitioner.
Contraindications:
You cannot have Skinko-E mesotherapy treatments if:
You are allergic to any of the ingredients within Skinko-E.
You have had roaccutane/Isotretinoin medication in the last 6 months.
You have an active infection or inflammation near the intended treatment area, including active acne lesions.
You have active Eczema or Psoriasis in the treatment area.
You have an active outbreak of herpes simplex infection (Cold sores).
You have a history of keloid or raised scarring.
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 active acne/rosacea in the intended treatment area.
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 have had facial fillers in the intended treatment area 2 weeks prior.
You think you could be pregnant, are pregnant, or are lactating or breastfeeding.
Cautions:
You need to tell your aesthetic practitioner if:
You have an upcoming important event. You will have a visible redness to the skin and may experience bruising for several days. You should plan your treatment and social/work diary around this and allow at least 2 weeks between treatment and the event.
You suffer from recurrent herpes simplex (cold sores) infections near the intended treatment area. Skinko-E mesotherapy may encourage an outbreak. Patients with a history of cold sores may be given an antiviral three days before treatment.
You are taking blood thinning medications.
You are taking retinoid medications.
You are on immunosuppressive therapy, or therapy used to decrease the body’s immune response.
You have diabetes.
You have a history of eczema and /or psoriasis.
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:
Pain or discomfort: Some discomfort may be experienced during the procedure. Please let your practitioner know at any time if you want to stop. Following the treatment, you may experience a sunburn-like sensation for 1-2 days.
Herpes (cold sores) re-activation. There is a risk of an outbreak of herpes cold sores in individuals who already carry the herpes virus. You should manage this as you would typically, such as using over-the-counter cold sore medication. Please get in touch with your practitioner if you experience a severe outbreak following treatment, where a prescription medication may be required.
Skin redness. Skin erythema (skin redness) is the most common and likely side effect of your treatment. This is a positive side effect that is part of your skin healing response. It will usually last 1-2 days but may last longer.
Dry, flaking skin. This usually occurs two to three days post-treatment and lasts up to ten days. This is where your upper epidermal skin cells are shedding, with the generation of new healthy skin cells in its place.
Treatment site bruising, mild swelling. These symptoms are usually mild and last less than a few days 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.
Infection. As with any procedure that involves a break to the skin’s surface, a Skinko-E mesotherapy treatment carries the risk of infection, although it is rare. You should inform your practitioner if swelling, heat, and/or discomfort occur in the treated area for longer than a few days. This may require medical intervention, such as antibiotic therapy.
Hyperpigmentation. Although Skinko-E Mesotherapy can reduce skin pigmentation, post-inflammatory hyperpigmentation can occur in certain individuals.
Allergy. Rarely allergic reactions or anaphylactic shock may occur with the injection of Skinko-E. Please contact your practitioner immediately if you experience severe skin swelling, itching or hives post-treatment. You must visit your local A&E department if you experience swelling in the lips, tongue, or throat. This could be a sign of anaphylaxis and is a medical emergency.
Scarring. There is a minimal risk that the areas treated may cause scarring or skin marking, which could be temporary or permanent.
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.
Informed Consent:
This consent form is not meant to include all possible risks associated with a Skinko-E mesotherapy treatment, 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, the reasons why you may not be able to receive treatment, and the known risks of a Skinko-E mesotherapy treatment.
By signing this consent form, you acknowledge and confirm the following:
Risks and complications
You have discussed the potential risks and benefits of Skinko-E mesotherapy 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 a Skinko-E mesotherapy treatment, and you 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 severe 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 with your practitioner to your satisfaction. You consent to receive a Skinko-E mesotherapy 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.
