I the undersigned, hereby consent to and authorize Padra Medical Center to carry out DERMAPEN / Potenza MICRONEEDLING RADIOFREQUENCY WITH COMBINATION OF MESOTHERAPY.

• I am undergoing treatment of my own free will, I agree that this procedure is being performed for cosmetic reasons and that no guarantees can be made as to the exact results of the procedure.
• I have disclosed any old or recent medical history including allergies such as atopic dermatitis, asthma, hypersensitivity to insects and bites, and medications I am allergic to or currently taking.
• I understand that every precaution will be taken to prevent complications and although complications from this procedure are rare. They can and sometimes do occur.

 

I have disclosed any old or recent medical history including:

• ALLERGY, DERMATITS, ANGIOAEDEMA, SENSITIVITY TO ANY DRUGS, RECENT OR OLD SURGICAL PRODECURES.
• HISTORY OF PERMANENT FILLERS.
• ANY RECENT INFLAMMATION OR INFECTION IN HEAD & NECK OR OTHER AREAS OF THE BODY.
• ANY HISTORY OF DIABETES, LOW IMMUNITY, OR ANY IMMUNE SUPPRESSING DRUGS.
• ANY HISTORY OF EPILIPTIC FITS.

 

POTENTIAL SIDE EFFECTS

I have been informed of the potential complication that may occur within four weeks or more after my treatment such as bruising, temporary swelling, discomfort, and erythema at the site of procedure. Although uncommon, I was also informed of a small number of patients who experienced localized reactions that are hypersensitive in nature such as allergy, itching and swelling at the procedure site, sometimes affecting the surrounding tissues, redness, tenderness, and rarely acne-like formations have also been reported. These reactions have also been described as mild to moderate and self-limiting, some significant and substantial

risks/drawbacks of this procedure include skin necrosis, allergic reaction, skin fistula, scar, facial thrombosis, and cellulitis of the face.

I am aware that there are personal variations, and the results may vary from person to another

To avoid such side effects after the procedure, I must:

• Not do any sports, expose to hot water (Shower/Swimming) or no sunlight for 3 days
• Not take any aspirin or ibuprofen or vitamin E for 24 hours following the injections
• Avoid any massage to the injection area for 2 weeks after the procedure
• Avoid any cosmetology treatment such as peeling, dermabrasion and sauna, facial and laser for two weeks after the procedure
• Avoid the usage of all kinds of creams and ointments without doctor’s prescription

I have read this information, it has been explained to me, and I understand it. All my questions were answered, as I was given post-treatment instructions.

By signing this form, I indicate that I have no questions and give my full informed consent to have this procedure carried out on me.