Informed Consent for Micro Needling with the MD PEN Device with/without PRP/Stem Cell Growth Medium Name * First Name Last Name Email * Phone (###) ### #### Date MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country DOB MM DD YYYY Retinols and any hydroxy acids use must stop 7 days prior and post treatment. To reduce bruising please refrain from using any Aspirin, Motrin, Ibuprofen 7 days prior and post treatment. If you are prone to cold sores, we recommend you contact you Primary Care Provider to obtain a prescription for Valtrex. We recommend 2 gm the morning of the treatment and another 2 gm 12 hours later. We WILL NOT perform the treatment with any of the following: Use of blood thinners, current cold sore, ANY infection or illness, pregnancy, use of corticosteroids, rash in treatment area, active acne breakout or open sores. Do not shower for at least 6 hours, and exercise for 12. No lotions or creams for 6 hours after the procedure, and you should only use a gentle wash, light lotion and a physical block SPF for the next week. Smoking and alcohol should be avoided for at least 3 days to heal quickly and properly. It is recommended that you consume at least 64 ounces of water a day for the next few weeks. A physical block sunscreen (titanium dioxide and zinc oxide) of at least SPF 30 should be worn daily for at least 2 weeks, no matter what season the procedure is performed during. I certify that I have read the above information and have been informed of the treatment instructions and possible risks after and have adhered to all pre procedure requests and will continue the post procedure recommendations. I release epic MedSpa and its Doctors, and employees from any and all liability arising from or in connection to this procedure. By submitting this form I understand and acknowledge all of the aforementioned information. Thank you!
