Consent for the Vampire Facial® Microneedling Facial Procedure

A. CONSENT FOR VAMPIRE FACIAL® PROCEDURE I have received information about my condition, the proposed treatment, alternatives, and related risks. This form contains a brief summary of this information. I have received an explanation of any unfamiliar terms and have been offered the opportunity to ask questions. I have not received any promise, guarantee or warranty that my undergoing the Vampire Facial® procedure will achieve a particular result. I fully understand that individual results do vary, and that Halo Med Spa and its staff assumes no responsibility for failure to achieve a desired result.

I understand I may refuse consent and I GIVE MY INFORMED AND VOLUNTARY CONSENT to the proposed procedures and the other matters shown below. I also consent to the performance of any additional procedures determined in the course of a procedure to be in my best interests and where delay might impair my health.

1. I authorize Halo Med Spa staff to treat my condition, including performing further diagnosis and the procedures described below, and taking any needed photographs.

2. I understand the proposed Vampire Facial® procedure(s) to be: a microneedling facial procedure for rejuvenating the skin of the face using blood-derived growth factors platelet-rich fibrin matrix (PRFM), platelet-rich plasma (PRP) injections.

3. I understand the risks associated with the proposed procedure(s) to be:
Bleeding
Infections
No effect at all
Allergic reactions
Alteration of facial features
Hematoma
Need for subsequent surgery
Scar formation
Local tissue infarction and necrosis
Erosions
Fatigue
Damage to eyes, ears, nose, mouth
Post-operative pain
Prolonged pain
Intractable pain
Failed procedure
Varied results
Psychological alterations
Relationship problems
Possible hospitalization for treatment of complications
Lidocaine toxicity
Anesthesia reaction
Embolism
Depression
Reactions to medications including anaphylaxis
Nerve damage
Permanent numbness
Slow healing
Swelling
Allergy
Nodule formation

4. I also understand that there may be other RISKS OR COMPLICATIONS, OR SERIOUS INJURY from both known and unknown causes. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the risks of the procedure.

5. I understand that the use of PRP in this procedure is an “off-label” use, and no promise or representation, guarantee or warranty regarding its use, benefit or other quality is made. No representations that the use of this product and this procedure is approved by the FDA or any other agency of the federal or state government is made. I understand the alternatives to the proposed procedures and the related risks to be: do nothing. CONSENT FOR ANESTHESIA When local anesthesia and/or sedation is used by the physician: I consent to the administration of such local anesthetics as may be considered necessary by the physician in charge of my care. I understand that the risks of local anesthesia include: local discomfort, swelling, bruising, allergic reactions to medications, and seizures.

B. PATIENT CERTIFICATION: By signing below I state that I am 18 years of age or older, or otherwise authorized to consent. I have read or have had explained to me the contents of this form. I understand the information on this form and give my consent to what is described above and to what has been explained to me.

I Understand & I Agree to the above *

I Agree

Patient Name *

First Name Last Name

Date *

Date

Patient Signature *

Sign with your finger or Mouse Clear

(SERVICE PROVIDER VERIFICATION) I have explained the procedure(s), alternative(s) and risks to the person or persons whose signature is affixed above. The patient has verbally communicated to me that they understand the contents of this form. *

I Have

Service Provider Signature *

Clear

Medical Director: Dr Don Hedeges, DO

Clear

I understand that although good results are expected, there cannot be any guarantee or warranty, expressed or implied, that I will be completely satisfied by the outcome or that I will not require additional treatment and/or ongoing treatment to achieve the result I seek. I understand that treatments will not cure any medical conditions nor provide immunity against re-occurrence of such conditions. The treatments are temporary and vary per patient with some patients experiencing shorter or longer effects. The number of treatments needed varies per patient and may be affected by the following factors including but not limited to: degree of skin irregularity; severity of volume loss; patient age; personal medical profile; basic metabolic rate; previous cosmetic procedures; history of trauma to the treated area; individual lifestyle choices; and individual patient preference. I understand that all product and service sales are final. No refunds on services or products. I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I agree to the terms of this agreement. I understand and voluntarily accept the risks associated with all the services provided at Halo Med Spa, including but not limited to: Waxing, Facials, Tanning, Injections, Laser Services and skincare products, ECT. or the use of any of the location’s facilities. Except where prohibited by law; I acknowledge and voluntarily assume the risk of injury, accident or death which may arise from the use of any skin care products or services performed by Halo Med Spa. I agree Halo Med Spa will not be liable for death or any injury, including, without limitation, personal, bodily or mental injury, economic loss or damage to me resulting from negligence, other acts in Halo Med Spa, anyone acting on Halo Med Spa's behalf, or anyone using the services of the facilities of Halo Med Spa, to the fullest extent permitted by law. This agreement together with Halo Med Spa's post-care plan rules and regulations, constitute the entire agreement between you and us and cannot be amended, except in writing by both parties. Myself and/or any of my heirs, executors, representatives, or assignees hereby release Halo Med Spa from all claims or liabilities for death, personal injury or property loss or damages of any kind sustained while on the premises. I agree that this form and waiver is in effect for all services offered by Halo Med Spa, and will not expire unless specifically requested by either party. I understand that Halo Med Spa is a tranquil and professional environment and that any inappropriate behavior may result in termination of my services and full payment is expected. I also understand that any medical device used by the patient outside of Halo Med Spa care or failing to list or mention such medical devices could result in unexpected or unwanted results. By signing this form, I agree to the above terms and release Halo Med Spa and its employees from any liability. In case of emergency contact Dr. Don Hedges DO at Northwest Medical Center 505-345-3572 or northwestmedicalcenterinc.com

I understand and agree.