RF Microneedling Consent
This consent form is designed to give you the information you need to make an informed decision about whether or not to undergo radiofrequency (RF) microneedling treatments.
The FDA-approved Vivace RF microneedling device combines microneedling with electrical energy at a relatively low temperature to target the deeper skin layer known as the dermis. This promotes the body's natural production of collagen and elastin. RF microneedling treatments may improve the appearance of: wrinkles, scars, acne scarring, pore size, texture, rosacea (redness reduction), stretch marks and overall skin rejuvenation. Treatments can be performed on any area of the face or body and on most skin types.
RF microneedling treatment involves the placement of a handpiece on the specific treatment area, the provider will then activate the electrical energy. The handpiece consists of a multiple needle head that targets a specific depth depending on each patient's desired result. The skin is anesthetized prior to treatment to ensure maximum comfort. When the microneedles puncture the skin, very tiny "fractionated wounds" are produced that stimulate new collagen formation in the skin, as well as the production of hyaluronic acid and elastin, which contribute to smoothing wrinkles and skin-tightening. The result is healthier, plumper and younger-looking skin. During the treatment, Platelet Rich Plasma (PRP) therapy may be combined to enhance cell regeneration and optimize results. Noticeable change in the skin is typically seen after 3 treatments, performed 4-6 weeks apart. While 3 treatments produce successful results for most, some patients may require additional treatments. Maintenance treatments are recommended once or twice a year after the initial series to boost and maintain results.
Alternatives to RF microneedling treatments include but are not limited to: laser resurfacing, chemical peels, surgical procedures (dermabrasion or face lift surgery), or no treatment at all.
Results vary with the individual and depend on multiple factors. However, results can continue to improve up to 6 months after treatment as the production of collagen and elastin continue to increase.
Tattoos and permanent makeup in the treatment area may be altered unintentionally. The physician or treating health care provider must be notified prior to treatment if you have these in or near the treated area and do not want them to be altered.
Patients with the following conditions may not receive RF microneedling treatments: a pacemaker or defibrillator, history of seizures, cystic acne in the treatment area, use of Accutane within the past 6 months, an allergy to anesthetics, history of abnormal raised scarring or keloid formation, inflammation or injury (i.e., an open wound) in the treatment area, pregnancy or lactation, and tanned skin or active sun exposure (including tanning booth use) 1 week prior to treatment. RSMD, Medical Aesthetics and the physician or treating health care provider must be notified by the patient of these conditions prior to treatments.
Possible risks, side-effects and complications of RF microneedling include, but are not limited to:
Discomfort or pain during and after the procedure in the treated areas that typically resolves in 2-3 days.
Pinpoint bleeding may occur during treatment.
Redness and swelling immediately after treatment that typically resolves within 1 week but may last longer. Swelling is most common around the eyes.
Skin dryness and possible flaking/peeling may occur 4-5 days after treatment, and last for 2-3 days.
Pigment changes such as hypopigmentation (skin lightening), hyperpigmentation (skin darkening or discoloration), worsening melasma and blotchiness may occur. Pigment changes can occur more frequently in darker skin types and usually resolve in three to six months but may be permanent.
Pinpoint, grid-like pattern scabbing may occur, which typically resolves within 2 weeks and may take up to 1-2 months.
Bruising may occur and typically resolves within 1 week.
Local or systemic allergies to topical skin care products may cause prolonged redness, itchiness and swelling.
Acne outbreak or milia.
In rare instances, infection may be activated which may require antibiotics or antivirals.
Viral infections such as herpes simplex (cold sores) or varicella (shingles) may be activated by treatments and a prescription may be required both prior to and following the procedure to help suppress a viral infection.
Blisters and burns are rare but may occur.
Scarring is rare, but can occur and is seen most often in patients with a history of keloids.
The risks of RF microneedling may not be fully known and RSMD, Medical Aesthetics is not responsible for any risks or unforeseen complications not yet discovered or not commonly known.
Topical anesthesia (e.g., benzocaine/lidocaine/tetracaine cream or ointment) complications include, but are not limited to: skin irritation, lightheadedness, rapid heart rate, visual disturbance, tongue numbness and rare cases of seizures or death. Apply the anesthetic medication sparingly as instructed to the most sensitive areas.
Direct sun exposure must be avoided during treatments and for a period of approximately 1 week after treatment with daily use of sunscreen containing titanium dioxide or zinc oxide SPF 30 or greater.
I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees can be or have been given to me by anyone regarding the treatment results or how long any improvement will last. I understand that I may not derive any benefit from treatments and that there are no guarantees against side-effects or complications.
I consent and authorize Dr. Small, her physician assistants, and nurses to perform RF microneedling treatments and any related treatments that may be deemed necessary or advisable during or after the procedure. This includes but is not limited to topical anesthetics (e.g., benzocaine/lidocaine/tetracaine cream or ointment). This consent shall apply to all subsequent treatments. During the procedure, unforeseen conditions may necessitate additional or different procedures than those set forth above and I therefore, authorize and request that Dr. Small her physician assistants, and nurses to perform such procedures deem necessary, including but not limited to procedures involving pathology or radiology. This granted authority shall extend to remedying conditions that are not known to Dr. Small at the time the procedure is commenced. I understand that additional costs for any follow-up treatments or procedures necessary to diagnose or treat these conditions are additional to the cost of my RF microneedling treatment. I release from liability the providers, medical staff, specific technician, and RSMD, Medical Aesthetics, its members, employees, and affiliates from liability associated with this procedure.
I have fully disclosed all of my medical history including any serious medical problems, history of viral infection (such a herpes), and/or injuries and will update the provider of any change in my health status and medical history as it may affect my treatment outcome and increase the likelihood of complications. All information provided to RSMD, Medical Aesthetics is, to the best of my knowledge, true and correct.
I consent to be photographed. Photographs shall be part of the medical record and may be used for educational purposes and marketing.
My signature below certifies that I am an adult of at least 18 years of age. I have fully read this RF microneedling Treatment consent form and understand the potential benefits, limitations, alternative treatments, and I have had all questions and concerns answered to my satisfaction. I understand and accept the risks, side effects and possible complications inherent in undergoing RF microneedling treatments. I will contact RSMD, Medical Aesthetics at (831) 475-1077 if I have any question or problem regarding my treatments. I certify that I have fully read and agree to adhere to the pre-procedure and post-procedure instructions with each appointment. I understand that failure to carefully follow these instructions may affect my treatment outcome and increase the likelihood or severity of complications. Any applicable paragraphs were stricken before I signed. I also state that I speak, read and write English or have had all the information on this form translated to my satisfaction in my language.
RF Microneedling Pre & Post-Treatment Instructions
Prior to Treatment
Refrain completely from tanning, direct sun exposure, self tanner use, and spray tans for 1 week prior to treatment.
Use sunblock daily with zinc oxide or titanium dioxide (SPF 30 or greater).
Discontinue use of glycolic, retinol, and Retin-A containing products 1 week before treatments.
Avoid deep facial peel procedures for 1 month prior to your treatment (e.g. aggressive chemical peels, laser resurfacing).
If you have a history of herpes (cold sores) or shingles in the treatment area start your prescribed anti-viral medication (e.g., valacyclovir, acyclovir) 2 days prior to treatment and continue for 3 days after treatment.
Avoid Ginko biloba, vitamin E, aspirin products (e.g., Excedrin) for 2 weeks prior to the procedure to minimize bruising risk. Avoid anti-inflammatory medications such as ibuprofen (Motrin, Advil), naproxen (Aleve), celecoxib (Celebrex) for 1 week prior to your procedure. Acetaminophen (Tylenol) is fine.
If you have been prescribed Tramadol (Ultram) take as directed 1 hour prior to procedure.
The treatment area must be free of any cold sores, lesions, rashes, infections (e.g., active acne) and sunburn or the procedure may be rescheduled. Patients must notify RSMD at (831) 475-1077 if they have these conditions or develop any other illness prior to the date of their procedure.
Approximately 1 week prior to procedure come to RSMD during office hours to review pre and post procedure instructions, topical anesthetic ointment (BLT), products, make-up with a Patient Coordinator.
Obtain supplies for pre- procedure from RSMD:
Alcohol prep pads
Topical anesthetic ointment (BLT)
On the Day of Treatment
Eat a solid meal before coming to your appointment. Drink 6-8 glasses of water.
Remove all make up.
Take medications if indicated (e.g., for prevention of herpes or for pain 1 hour before procedure) as prescribed.
Clean the treatment area with alcohol.
Apply a thin layer of topical anesthetic ointment (BLT) to cleanly washed treatment area 1 hour prior to the procedure. For treatment of the face, make sure to apply BLT along the border of the upper lip, into the hairline, close to the ears, and under the tip of the nose. RSMD will remove it at your visit.
After Treatment
Immediately after procedure, there may be pinpoint bleeding and the skin may be red, have tiny bumps, and feel sensitive/sunburned. This typically resolves in 2-3 days.
Day 2-6 the skin will be less red and should not feel uncomfortable but may feel dry, itchy, and have tiny bumps. You may see pinpoint brown/black dots, these are micro-crusts. These micro-crusts and tiny bumps typically resolve over 1-2 weeks and may take up to 1 month, especially in non-facial areas. Do not pick, scratch or remove. Keep the treated area hydrated with SkinCeutical’s Hydrabalm or Epidermal Repair.
Swelling of the treated area, particularly around the eyes and cheeks may be present. For swelling, apply a wrapped ice pack for fifteen minutes every 1 – 2 hours the day of treatment and for a few days after if needed. You may take an oral antihistamine (e.g., cetirizine [Zyrtec] 10mg 1 tablet in the day time and/or diphenhydramine [Benadryl] 25mg 1 tablet at night). In addition, you can sleep with your head elevated to help reduce swelling.
Apply the recommended post-procedure skin care products as directed. The treatment area should be kept moist on the day of treatment.
Remember to drink plenty of fluids.
If significant swelling in the treatment area, take a non-sedating antihistamine daily in the day time (e.g. Zyrtec 10mg or Claritin 10mg) and if needed Benadryl (12.5-25mg) in the early evening. Please call our office if this occurs
For itchiness, an oral antihistamine (Benadryl) may also be used. Do not scratch treated areas. If itchy for more than 2 days, contact RSMD.
Avoid irritants such as glycolic, retinol, and Retin-A products (e.g., toners, exfoliants, astringents, prescription or over-the-counter anti-aging products) for 2 weeks following the procedure, or until advised by the RSMD skincare specialist.
Clean items that contact your face using alcohol (i.e., glasses, cell phone).
Light exercise (e.g., walking, gentle yoga) is fine 24 hours after treatment. Avoid strenuous exercise (e.g., Crossfit, hot yoga, hot pilates, running) for 72 hours after treatment
Avoid direct sun exposure, tanning, and spray tanning for at least 1 week, or until all redness in the treatment area is fully resolved. Sun exposure increases the risks of certain procedure complications such as pigmentation changes (i.e., darkening or discoloration of the skin).
Avoid facial treatments for one month, such as microdermabrasion, chemical peels, and facial waxing.
Acne lesions or milia (small white bumps) can occur up to a month after the procedure. Please contact RSMD if you develop acne or milia.
Mineral make up may be applied on day 2, use clean make up brushes.
If you have any questions or concerns, please contact RSMD Medical Aesthetics at (831) 475-1077. If problems arise after hours, please go to your nearest urgent care facility.