DESCRIPTION OF TREATMENT:

The AnteAGE® hair treatment captures the power of natural, rejuvenating Growth Factors, delivered to the scalp using Medical Microneedling (also known as Dermal Needling or Collagen Induction Therapy). Microneedling creates microscopic perforations in the upper layers of the skin. The minor, controlled trauma initiates a natural healing process which promotes platelet and epidermal growth factors through platelet activation and skin wound regeneration mechanisms, activation of stem cells in the hair bulge region and overexpression of hair growth-related genes including VEGF, B catenin and WNT, among others. Supplemented with the AnteAGE® Hair Microneedling Solution, the treatment area is flooded with additional biological signals to enhance and optimize follicular communication and signaling pathways. Depending on the purpose of the treatment, needle lengths may vary from 1.0 mm to 1.5 mm. For the first few hours after Microneedling, penetration of topically applied actives is greatly enhanced. For this reason, it is important to apply only bio-signaling molecules (such as AnteAGE® Cytokines and Growth Factors). Growth Factors and Cytokines can reduce inflammation, promote protein synthesis, and new cell growth. Microneedling with needles 0.5 mm and longer generally requires anesthetic pre-treatment. This is typically accomplished by applying a local topical anesthetic for 30 minutes prior to treatment. For aggressive treatments, anesthetic injections can be used for pain control.

Mr. / Mrs. / Ms. / other:

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Emergency Contact Name:

First Name

Last Name

Contact Number:

(###)

###

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Relationship to Person:

Email:

Date of Birth:

YYYY

Occupation:

Pain relief option chosen:

Topical applied at:

Removed at:

Area/s to be treated:

Previous surgical and non-surgical hair treatments:

Previous cosmetic procedures in treatment areas:

CONTRAINDICATIONS

Microneedling is contraindicated on irritated skin, infected skin, fungal skin infections, active rosacea, eczema, psoriasis, severe solar keratosis, skin cancer, raised moles and/or warts, and/or any large open wounds or sores. Patients with a history of herpes should discuss the details of their outbreaks with the physician. Depending on history, it may be necessary to initiate oral prophylaxis for a day or two prior to and after treatment. If you are unsure about any of above mentioned conditions, please ask!

Comments:

Have you ever been told that you suffer from or suspect you suffer from: Platelet dysfunction syndrome, critical thrombo- cytopenia, hypofibrinogenaemia, haemodynamic instability, sepsis, chronic liver disease, Hepatitis or any acute or chronic infections?

Yes

If yes, please state:

MEDICATIONS & ALLERGIES:

List all medications that you are currently taking or have taken in the last week: (prescription, herbal, and over the counter meds):

Have you taken antibiotics in the last week?

Yes

If yes, specify:

Are you allergic to medications? (include prescription and over the counter meds, and the type of reaction):

Are you allergic to latex, lidocaine or any lotions?

Yes

Are there any open wounds or infections in the area being treated?

Yes

Name of your family doctor / GP:

Doctor Phone:

(###)

###

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Signature

I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, nurse, or doctor of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

First Name

Last Name

Patient Information & Consent

For AnteAGE® Micro-Needling Hair Treatment

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