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Microneedling Dp4 Client Informed Consent Form

Let us do this part
Today's Date:
Sun May 18 2025 09:14
Please read and answer
 
WHAT ARE YOUR PRIMARY SKIN CONCERNS THAT YOU WISH TO BE TREATED WITH DERMAPEN 4TM?
 
Y
N
DO YOU HAVE ANY KNOWN ALLERGIES?*
(Eg. latex, metals, shellfish, nuts, penicillin, anesthetic agents,
P-aminobenzoic acid [PABA], sulphonamide allergies.)
Details:
 
Y
N
ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING ACTIVE SKIN CONDITIONS?*
Papulopustular rosacea
Acne vulgaris stage III-IV
Herpes simplex
Dermatomyositis
Warts
Scleroderma
Pemphigus/pemphigoid
Bacterial/fungal Infections
Open lesions
Solar keratosis
Skin cancer
Psoriasis
Undiagnosed/unusual moles
Lupus erythematosus
Collagen vascular diseases
Vitiligo
Keloid scars
Other
Details:
 
Y
N
HAVE YOU EVER EXPERIENCED ANY ADVERSE REACTION TO ANY FORM OF ANAESTHETIC?*
Details:
 
Y
N
ARE YOU CURRENTLY UNDER MEDICAL SUPERVISION FOR ANY OF THE FOLLOWING?*
Cardiac conditions/arrhythmia
Auto-immune disorder
Haemophilia
Hepatic disease
Human Immunodeficiency Virus (HIV)
Pseudo cholinesterase deficiency
Congenial or idiopathic methemoglobinemia
Diabetes (type I or II)
Cancer
Atopy/allergies
Other chronic illness
Details:
 
Y
N
ARE YOU CURRENTLY PREGNANT OR BREASTFEEDING?*
Y
N
ARE YOU CURRENTLY TAKING (OR HAVE TAKEN IN THE LAST 3 MONTHS) ANY OF THE FOLLOWING MEDICATIONS OR SUPPLEMENTS? (Please tick.)*
Isotretinoin (including but not limited to Roaccutane®/Accutane®/Isotane®)
Anti-coagulants/blood thinners (including but
not limited to Warfarin, aspirin, or
immunosuppressant medications)
Photo-sensitisers (including but not limited to
anti-depressants/anti-anxieties/antibiotics)
Contraceptive pill
Fish oils/plant oils/omega 3s
Ginseng/gingko biloba/St John’s wort
Details:
 
Y
N
HAVE YOU HAD ANY OF THE FOLLOWING PROCEDURES IN THE LAST 2 WEEKS ON THE AREA TO BE TREATED WITH DERMAPEN 4TM? (Please tick.)*
Plastic/cosmetic surgery
Botulinum toxin/BTX/muscle relaxant/wrinkle
reduction injections (including but not limited to
Botox®/Vistabel®, DysportTM/AzzalureTM Xeomin®/
Bocouture®)
Long-term/semi -permanent injectables (including but
not limited to Aquamid®, Sculptra®, Artefill®)
Microdermabrasion
Derma blading/derma planing
Laser/IPL rejuvenation/hair removal
Tattooing/cosmetic tattooing
Electrolysis/diathermy
Radio Frequency (RF) skin tightening
Dermal fillers (including but not limited to
Juvederm®, Restylane®, Teosyal®, Princess®, Stylage®,
Esthelis®, Radiesse®, Belotero®, Captique®)
Photo dynamic therapy (PDT)
Chemical peel (including but not limited to glycolic
acid, lactic acid, mandelic acid or salicylic acid)
Dermabrasion
Deep chemical peel
Hair removal (including but not limited to waxing,
sugaring, plucking, threading or depilatory cream)
Spray/self-tanning
Details:
 
Y
N
HAVE YOU USED ANY PRODUCTS CONTAINING ANY OF THE FOLLOWING INGREDIENTS ON THE AREA TO BE TREATED WITH DERMAPEN 4TM IN THE LAST WEEK? (Please tick.)*
Resurfacing agents (including but not limited to
alpha-hydroxy-acids, salicylic acid)
Retinoids/retinoid-like agents (including but not
limited to tretinoin/retinoic acid, tazarotene,
adapalene, retinol)
Antimicrobial agents (including but not limited to
benzoyl peroxide, isopropyl alcohol)
Bleaching/depigmenting agents (including but not
limited to Kligman’s Formula, hydroquinone)
Details:
 
Y
N
Consent*
I, ...........................Sign below............................................., have completed the Dermapen 4TM Treatment Consultation & Consent Form
honestly and to the best of my knowledge. My Dermapen 4TM Authorised Treatment has thoroughly explained to me:

• What a Dermapen 4TM treatment is
• How a Dermapen 4TM treatment works
• Expected outcomes of my Dermapen 4TM treatment
• Dermapen 4TM treatment contraindications and considerations
• Anaesthesia protocols - pros and cons
• Post-op care with Dp DermaceuticalsTM

I understand that a course of Dermapen 4TM treatments will be required for optimum results.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Name:*
Address:*
Postcode:*
Date of birth:*
Phone #:*
Email:*
Signature:*


Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #: