DPW ATP Form Dermapen Informed Consent BER Peeling

I acknowledge that no guarantee has been made about the results of the procedure. Although it is impossible to list every potential risk and complication, I have been informed of the possible risks and complications, which may include, but are not limited to, the following: • stinging, itching, irritation • redness and swelling of the skin • tightness, peeling or scabbing of treated skin and the surrounding areas • prolonged skin sensitivity to wind and such environmental elements • period of possible dryness, itchy or irritation; my skin may appear older during the phase of skin renewal. I acknowledge that no guarantee has been made about the results of the procedure. Although it is impossible to list every potential risk and complication, I have been informed of the possible risks and complications, which may include, but are not limited to, the following: I certify that I am over the age of eighteen (18) and that: • In the last 12 months I have not used Accutane, isotretinoin (or its generic form) or received chemotherapy or radiation therapy. • I am not pregnant or breastfeeding. • I do not have a history of radiation to the treated area. • I do not have active herpes simplex or active infection. • I do not have a history of keloid scar formation. • I have not waxed in the past fortnight or shaved the treated area for 24 hours. • I have not used Retin A, benzoyl peroxide or similar medications for 2 weeks. • I WILL protect my skin from direct sun for 3 days post procedure. • I WILL use a broad-spectrum sunblock every day (such as Dp Dermaceuticals COVER RECOVER) and reapply when necessary. • I WILL avoid hot baths/showers, sweating and strenuous exercise for 3–5 days post procedure. • I WILL avoid rubbing, picking and scrubbing my skin post procedure, for I understand it could lead to scarring. • I WILL NOT use retinoids or other exfoliating agents until my skin is healed. I have read and will follow to the best of my ability any and all instructions. I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations, and alternatives.