Potenza Microneedling Consent Form

As a client, it is important for you to understand the expected results and risks of radiofrequency microneedling treatment with the Potenza Microneedling System. Please read this document carefully. Before signing this document, please ask your physician, or the consultant providing the RF treatment, about any aspect of this document or the procedure that you do not understand. Potenza System equipment may present a hazard to clients with implantable devices.

Please consult qualified medical personnel prior to being treated with radiofrequency equipment. Since ongoing feedback by a client during a procedure is required, if there is nerve insensitivity to heat anywhere in the treatment area, the client should not be treated with the Potenza System. All clients should be free of infection prior to application. Infection can further increase the risk of scarring; therefore, proper wound care is important in the prevention of infection. If signs of infection such as pain, heat, blisters or surrounding redness develop following application, call the provider’s office immediately.

The application will involve applying low level heat to the tissue using radiofrequency for therapeutic purposes.

During Treatment

All jewelry and lotions should be removed from the treatment area prior to treatment. The procedure should not be performed on cut, wounded or infected skin as this could promote infection and injury. Although uncommon, burns can occur.

Slight discomfort may be experienced while undergoing treatment. Typically, the discomfort is mild and temporary during the procedure and localized within the treatment area. During the treatment, you should provide ongoing feedback to the individual performing the treatment. Additionally, if you have nerve insensitivity to heat anywhere in the treatment area, you should not be treated. Inadequate or impaired feedback may lead to burns or injury. Ongoing feedback should be provided by the client to the individual performing the treatment to avoid excessive discomfort.

After Treatment

Studies indicate the possible side effects of Potenza System are usually treatment-site related and include mild discomfort during the procedure, localized within the treatment area. Mild swelling and redness may occur, which typically goes away within 2 to 24 hours.

A regimen to moisturize and soothe the external skin posttreatment is recommended. There is the possibility that additional risk factors of radiofrequency skin treatments may be discovered. The results of performing RF tissue-heating treatments in combination with other treatments is unstudied and unknown.

 

Possible Side Effects

  • Erythema (redness) may occur after the treatment, lasting a few hours and up to three days.
  • Tissue may be edematous (swollen) for a few hours up to several days.
  • Pinpoint bleeding on the surface of the skin can be expected with deeper treatments.
  • Bleeding is temporary and is typically resolved by the end of the patient’s visit.
  • Small areas of micro crusting or scabbing.
  • Temporary tingling which typically resolves within 48 hours

It has been explained to me that this is a cosmetic procedure and not covered by insurance. It has been explained to me that more than one treatment may be recommended to achieve the best results. As mentioned before, there is no guarantee of results and no refund of payments for the procedure will be made.

I have been informed that hyperpigmentation (darkening of the skin), and hypopigmentation (lightening of the skin) are possible complications of the procedure:

My signature below signifies that all of my questions have been answered by the physician or consultant. I understand the risks, complications, expected results, and expense of the treatments. I have read and understand this document and give my consent to receive treatment with the Potenza System.

NOTE: All clients are different and exact results of this cosmetic procedure and treatments cannot be predicted or guaranteed.