MicroNeedling or MicroNeedling with PRP Consent Form for a Minor

Lakeside Dermatology

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have received a consultation and hereby give consent to Lakeside Dermatology and its assistants to perform PRP injection procedures on my child, even in the event that I am not there. I also consent to any other medical services during the procedure that may become medically reasonable and necessary. This includes, but is not limited to, the administration of anesthetics necessary to perform PRP injections.

The MicroNeedling treatment allows for controlled induction of platelet rich plasma or hyaluronic acid, into the skins self-repair process by creating micro injuries in the skin. These injuries stimulate new collagen production, while not posing the risk of permanent scaring. The result is smoother, firmer and younger looking skin. The skin needling treatments are performed in a safe and precise manner with a sterile needle head and are usually completed in 30-60 minutes.

Side Effects Typically Include:
• Skin will be pink or red and may feel warm, like mild sunburn, tight and itchy, which usually subside in 12 to 24 hrs
• Minor flaking or dryness of the skin, with scab formation in rare cases.
• Crusting, discomfort, bruising and swelling may occur.
• Pinpoint bleeding.
• It is possible to have a cold sore flare if you have a history of outbreaks.
• Freckles may lighten temporarily or permanently disappear in treated areas.
• Infection is rare but if you see any signs of tender redness or puss notify our office immediately.
• Hyperpigmentation (darkening of the skin) rarely occurs and usually resolves itself after a month.
• Permanent scarring (less than 1%) is extremely rare.

I understand that if my child has MicroNeedling with PRP that his/her blood will be drawn and spun to extract the platelet rich plasma. The plasma portion of the blood will be used as part of the treatment. I acknowledge that with any blood draw that bruising may occur at the needle stick site.

I have been informed about the treatment, procedure, indications, expected results and possible side effects. I understand that my child is required to have photographs taken before, during and after treatment for his/her medical records.

Although the results are usually dramatic I have been informed that the practice of medicine is not an exact science and that no guarantees can be or have been made concerning the expected results.

I understand that the PRP injection procedures are “elective” procedures. I agree that this procedure is being performed for cosmetic reasons. I am also aware of and accept the risk of unforeseen complications that may not have been discussed and which may result from this treatment.

I acknowledge my obligation to follow the instructions closely and visit the office as directed. I certify that I have read the above consent agreement and fully understand it. These items have been reviewed and discussed with the doctor/nurse/skin care specialist and all my questions have been answered to my satisfaction. I also agree to hold harmless and release from any liability Lakeside Dermatology or any of its officers, directors and / or employees for any condition or result, known or unknown that may arise as a result of any treatment that my child receives.

DISCLAIMER: By signing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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