We are 100% committed to the health and well-being for everyone. We are doing everything we can to keep potential exposure out of our office.

As part of the local and state guidelines you must answer no to all the following questions each time you enter Pua Manu Medspa.

• Not present a fever over 100 F/ 37 C.
• Not presenting cold, cough, difficulty breathing muscle pain, headache,
  loss of taste/smell or pink eye in past 14 days.
• Not in contact with anyone with these symptoms in the past 14 days.
  Not currently under quarantine order or directive.
• Not in contact with anyone diagnosed with COVID-19, sick and quarantined, in the past 14 days.

All information above is true. I may be asked again when I arrive for my appointment. 
ALL PATIENTS AND STAFF ARE REQUIRED TO: 

• Please follow our local and state regulations and guidelines, including those related to occupancy levels, social distancing and other measures intended to reduce the spread of viruses.
• Stay home if you are sick or are exhibiting symptoms of illness such as a fever or persistent cough.
• Face mask are required to enter the Spa.
• Refrain from shaking hands or other touching rituals.
• Wash hands for 60 seconds with soap and warm water prior to treatment or use hand sanitizer.
• Refrain from eating or drinking while in the Spa, face mask should not be removed. 

I agree to comply to the rules listed above.

 

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact, and as a result, federal and state health agencies recommend social distancing. I understand that Pua Manu Medspa has put in place reasonable safety measures to help reduce the spread of COVID-19.

I understand that COVID-19 may cause additional risks, some of which may not be known at this time.

I understand that I am consenting to an elective treatment/procedure that is not urgent or emergent. I understand that it may put me at increased risk for becoming infected with COVID-19, due to potential community exposure.

PATIENT’S ACCEPTANCE OF RISKS

By signing this consent form I accept the risks described above and give my permission to proceed with the treatment/procedure.

I have read this consent or someone has read it to me and want to proceed.

About the Procedure

This procedure is performed by a trained healthcare professional, physician, or physician assistant, who is licensed to practice medicine in the State of Hawaii. The AGNES procedure is performed in a safe and precise manner with a single-use sterile micro-insulated needle. The treatment session usually takes about 30-60 minutes, depending on the area(s) being treated. After the procedure, the treatment area(s) will be red, with mild swelling and/or bruising, and your skin might feel tight and sensitive to the touch. Although these symptoms may take four to fourteen days to resolve completely, they will be diminished significantly within a couple of days after the treatment. Risk of RF AGNES Micro-Needling includes

Infection

Although it is unusual, viral, bacterial, and fungal infections can occur anytime the integrity of the skin is compromised. Should infection occur, you must contact or return to our office immediately, as additional treatment will likely be necessary.

Pigmentation

Because of dermal penetration of the AGNES procedure, failure to follow post treatment instructions can put you at risk for hyperpigmentation. You MUST avoid sun exposure for a 1 to 2 weeks after the treatment. You should also wear a daily SPF facial moisturizer, which your doctor or esthetician can recommend. Lastly, avoid picking and/or peeling the skin during healing period.

Scarring

Although normal healing after the procedure is expected, abnormal scars may occur in both skin and deeper tissues. In rare cases, thickened or keloid scars may result. Scars may be unattractive and of different color than surrounding skin. Additional treatments may be needed to treat scarring.

Pain

There may be a very slight burning, scratchy, and irritated sensation to the skin. This is usually temporary and is gone within a few days after treatment. A sudden reappearance of redness or pain is a sign of infection and you should notify our office immediately. Persistent Redness, Itching, and/or Swelling Itching, redness, and swelling are normal parts of the healing process. These symptoms rarely persists longer than 24 hours. However, treatments received less than 4 weeks apart may induce prolonged symptoms. Allergic Reaction An allergic reaction from AGNES RF micro-insulated needling procedure is nearly impossible. However, it can cause you to be hypersensitive to any products used on the face since the procedure increases the penetration of topical substances. If an allergic reaction were to occur, you must contact our office immediately, as it may require further treatment.

Contraindications of Micro-Needling

Although it is impossible to list every potential risk and complication, the followings are recognized as the known contraindications to AGNES RF micro-insulated needling procedure. Furthermore, it is your responsibility to fully and accurately disclose all medical history PRIOR to the initial treatment, as well as provide any necessary updates at all future treatment sessions. If you have any of the condition listed below, you should bring it to the attention of your doctor PRIOR to signing this consent form. Blood Thinner Medications, Cardiac Disease / Cardiac Pace Maker, Chemotherapy or Radiation, Collagen Vascular Disease, Hemophilia / Bleeding Disorder or Skin Cancer Uncontrolled Diabetes, Vascular Lesions (Hemangioma)

Acknowledgement

My signature below acknowledges that I have read and understand the content of this informed consent. I have been given substantial opportunity to ask questions, all of which have been answered in a satisfactory manner. I am aware of the risks and benefits associated with the AGNES Micro-needling procedure, as well as available alternative treatments. I understand that AGNES RF micro-needling is an elective procedure, performed solely for cosmetic purposes, and is not critical to my health. On my own free will, I am requesting and providing my informed consent, to undergo AGNES RF Micro-Insulated Needling treatment(s) at the office located at Pua Manu MedSpa.

I understand that results can vary and that no guarantee, neither expressed nor implied, has been or will be, given to me regarding my results. I understand that I may need more than one treatment to see results.

Discounted or special priced treatments must be prepaid in full by first treatment appointment. Incomplete and/or cancelled treatments will be charged at regular/full price, NO refunds.

I understand that necessary photos will be taken before, during and after the course of my treatments for medical purposes and to evaluate treatment effectiveness. I understand that my photos will be kept confidential in my electronic patient record.

I assume all risks as my own and agree to hold harmless, Pua Manu MedSpa. their providers, estheticians, and any other staff member, affiliate, or independent contractor. I hereby release them from any liability, both seen and unforeseen, now and forever.