Acupuncture and Micro Needling by Suzanne
Consent Form

The purpose of Facial Rejuvenation is to create a younger and more vibrant appearance. A Facial Rejuvenation treatment involves facial massage and the insertion of acupuncture needles to the face and/or neck and the body in order to reduce the visible signs of aging. According to the theory of Traditional Chinese Medicine, there are meridians or pathways of Qi (energy) that flow throughout the entire body. Therefore it is possible for Facial Rejuvenation to address the energy of the entire body making it not merely a “cosmetic” treatment. Your complexion reflects the result of the state of Qi in your entire body. As with all Traditional Chinese Medicine treatments, like acupuncture, Facial Rejuvenation involves the patient in a gradual, healthful process that I customize for each individual. 
Micro needling penetrates the skin causing tiny micro traumas that induce the bodies natural ability to repair with collagen. The result is firmer, smoother, younger looking skin. This is different than a derma roller since it uses entry in a vertical fashion rather than puncture and drag that can cause scarring. The one time use of a sterile needle head is used in treatment. 

Your treatments may include other modalities in conjunction with massage and acupuncture and will be explained if they are required for your care. Facial Rejuvenation or micro needling is in no way analogous or a substitute for a surgical facelift. In receiving either treatment you may experience some of the following changes:

• Improved muscle tone
• Decreased puffiness around the eyes
• Firming of sagging skin
• Elimination or reduction of fine wrinkles
• Even skin tone and improved luster of your complexion

MICRO NEEDLE PROCEDURE
Your skin will be cleansed and an application of lidocaine will be used upon request. During this time you receive acupuncture to address specific areas to be treated and massage to neck and shoulders. Hyaluronic acid liquid will be used during the treatment to help moisturize the skin and promote healing. The micro needle procedure takes anywhere from 15-20 minutes. After procedure a calming lotion is applied. 

POST MICRO NEEDLE CARE
After treatment the skin will feel like you have a sunburn with slight redness and possible bleeding. Most people experience relief from the most intense sensations after 20 min. Slight redness and the sensation of sunburn usually goes away after 2 days. This is your body healing and rebuilding collagen. At this time it is important to stay hydrated, eat healthy get adequate rest and avoid sunlight. At home skin regimen will require more moisturizing while skin is rebuilding and please refrain from using glycolic acid and retinols for 3 days. Depending on the individual 3-6 treatments are ideal with 3 weeks between treatment.

MICRO NEEDLE CONTRAINDICATIONS
	•	Diabetes
	•	Keloid scarring
	•	Scleroderma
	•	Hepatitis C
	•	AIDS/HIV
	•	pregnant
	•	current cancer patient
 
OTHER TREATMENTS NOT OFFERED BY SUZANNE
Treatment for sagging skin of the jowl and neck, wrinkles, excess skin above and below the eyes, and excess puffiness under the eyes may be corrected by various methods including, but not limited to, surgical facelift, chemical peels, liposuction, injections, surgical threading, and laser treatments. Risks and potential complications including death, severe scarring, nerve damage, sloughing of the skin, lumpiness, swelling,
allergic reaction, and permanent discoloration are associated with these other forms of treatment.
 
RISKS OF FACIAL REJUVENATION AND MICRO NEEDLING
In undertaking any procedure, it is important to understand the risks involved with receiving Facial Rejuvenation. Although most patients received this technique do not experience complications, the potential side effects or risks are listed here:
1. Bleeding and/or bruising – as with acupuncture in general, when a needle is removed some minor bleeding may occur. This is normal and usually will not leave a bruise. Occasionally, a bruise or hematoma may appear. With bruising, it is important that you wear sunscreen when going outside. Topical or internal remedies will be discussed to address bruising if it occurs. If swelling persists, please contact the practitioner.
2. Infection – infection at the needle site is very rare after an acupuncture treatment because the needles are sterile. If you suspect infection at the needle site (i.e. redness, swelling, or warm to the touch), please contact      
              the practitioner. Additional treatment or referral to your M.D. may be necessary.
3. Damage to deeper structures – Facial Rejuvenation uses a very shallow insertion of needles into the skin.Deeper structures such as blood vessels, nerves, and muscles are rarely damaged during the course of a facial acupuncture treatment. If this does occur, the injury may be temporary or permanent.
4. Asymmetry – all facial structures are naturally asymmetrical. Results may vary from side to side due to the natural asymmetry, previous injuries on one side of the body, or severity of symptoms from one side or the other.
5. Nerve injury – injury to the motor or sensory nerves very rarely results from facial acupuncture. Nerve injuries may cause temporary or permanent loss of facial movements and feeling. Such injuries may improve over time. Injury to the sensory nerves of the face, neck, and ear regions may cause temporary or, more rarely, permanent numbness. Painful nerve scarring is extremely rare.
6. Needle shock – needle shock is a rare occurrence that can happen during any acupuncture treatment. If you feel faint or shaky during the treatment, please let the practitioner know immediately.
7. Allergic reaction – In some cases, local allergies to topical preparations may occur. Systemic reactions that are more serious may occur when herbs are used during an acupuncture treatment. Skin testing is done prior to application of any herbal preparations. Allergic reaction may require additional treatment or discontinuation of treatment. 
8. Delayed healing – delayed healing is a rare complication. Smoking and certain health conditions such as
             diabetes, chronic fatigue syndrome, to name a few, may delay the healing response of any of the afore   
             mentioned risks.
9. Unsatisfactory results – it is important to understand that you are not having a surgical procedure. The alternatives, risks, and comparisons of surgical procedures versus acupuncture have been discussed and
              outlined in this document. Please discuss any questions with the practitioner before treatment begins.
 
LONG TERM EFFECTS
Following your Facial Rejuvenation treatments, changes in facial appearance may occur as the result of the normal process of aging, weight loss or gain, sun exposure, stress, illness, or other circumstances not related to acupuncture. It has been explained that following lifestyle and dietary instructions may enhance the longevity of the Facial Rejuvenation treatment while non-compliance will adversely affect the longevity of the Facial Rejuvenation treatment. Additional, future treatments may be necessary to maintain results.
 
HEALTH INSURANCE
As with most cosmetic procedures, most health insurance companies do not cover the cost of the procedure or complications resulting from the procedure. Please contact your insurance company if you have questions about coverage.
 
EXPECTATIONS AND GUARANTEE
It has been explained that Cosmetic Acupuncture is not a surgical procedure. Your question regarding longevity of results and expected changes in your facial appearance have been answered. Although good results are expected, there is no guarantee or warranty either expressed or implied on the results that may be obtained.
 
FINANCIAL RESPONSABLITIES
The fee of $140 for Facial Rejuvenation or micro needling includes:
• Thorough cleansing of the skin 
• Facial massage of the face, neck and shoulders
• Insertion of sterile acupuncture needles or sterile micro pen needles on the scalp, face and body 
• Nutritional and lifestyle recommendations to promote healthier skin
 
DISCLAIMER
Informed consent documents are used to communicate information about the proposed procedure along with disclosure of risks and alternative forms of treatment. They are not intended to define or serve as the standard of acupuncture. However, informed consent documents should not be considered all-inclusive in defining other methods of care and potential risks. Standards of acupuncture are determined on the basis or all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve. The practitioner may provide you with additional or different information that is based on the facts in your particular case and the present state of knowledge within the field of acupuncture.
 
I have read the document, had my questions answered by the practitioner, understand the expectations and risks associated with Facial Rejuvenation and Micro Needling, and consent to the treatment.

Signed:                                                                                       Date:                                                     .