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The Practice Beauty Clinic
  • 73 Thames St, Sunbury-on-Thames
  • info@practicebeautyclinic.co.uk
  • 01932 783333
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  • Treatments

    Face & Neck

    Laser Hair Removal
    Acne Removal
    Age Spot Removal
    Dermapen
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    Geneo Facial
    Facial Contouring Fillers
    Juvederm Lip Fillers & Enhancement
    Anti Wrinkle Injections

    Body

    Laser Hair Removal
    Body Contouring
    Cellulite Removal
    Tummy Tuck, non-surgical
    Butt lift

    Hair

    Laser Hair Removal

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DPW ATP Form Dermapen Informed Consent


PATIENT DETAILS

EMERGENCY CONTACT DETAILS

(e.g. latex, metals, shellfish, nuts, penicillin, anaesthetic agents, P-aminobenzoic acid (PABA), sulphonamide allergies)

ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING ACTIVE SKIN CONDITIONS?

ARE YOU CURRENTLY UNDER MEDICAL SUPERVISION FOR ANY OF THE FOLLOWING?

ARE YOU CURRENTLY TAKING (OR HAVE TAKEN IN THE LAST 3 MONTHS) ANY OF THE FOLLOWING MEDICATIONS OR SUPPLEMENTS?

HAVE YOU HAD ANY OF THE FOLLOWING PROCEDURES IN THE LAST 2 WEEKS ON THE AREA TO BE TREATED WITH DERMAPEN?

HAVE YOU USED ANY PRODUCTS CONTAINING ANY OF THE FOLLOWING INGREDIENTS ON THE AREA TO BE TREATED WITH DERMAPEN™ IN THE LAST WEEK?

CONSENT

I have completed the Dermapen™ Clinical Treatment Consultation & Consent Form honestly and to the best of my knowledge. My Dermapen™ Treatment Provider has provided me with a Dermapen™ Pre-Treatment Form and a Dermapen™ Post-Treatment Form and has thoroughly explained to me: • What a Dermapen™ clinical treatment is • How a Dermapen™ clinical treatment works • Expected outcomes of my Dermapen™ clinical treatment • Dermapen™ clinical treatment contraindications and considerations • Anaesthesia protocols - Pros & Cons • Post-op care I understand that a course of Dermapen™ clinical treatments will be required for optimum results.
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The Practice Beauty Clinic

Our results-driven treatments combine the most innovative and effective technology, with safety of our clients in mind at all times in a GP led skin clinic.

Purchasing products? Payments through paypal or card. See our terms for details

Treatments

  • Laser Hair Removal
  • Skin Rejuvenation
  • Dermapen
  • Skin Peels
  • Vascular Lesions, Pigmented Lesions

Find Us

73 Thames Street
Sunbury on Thames
TW16 6AD
info@practicebeautyclinic.co.uk
01932 783333

Mon: 8am – 6pm
Tues: 8am – 6pm
Weds: 8am – 6pm
Thurs: 8am – 3pm
Fri: 9am – 6pm

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