DPW ATP Form Dermapen Informed Consent DATEDERMAPEN™ CLINICDERMAPEN™ PRACTITIONERPATIENT DETAILSFULL NAMEDATE OF BIRTHADDRESSTELEPHONE (M)(H)(W)EMAIL ADDRESSEMERGENCY CONTACT DETAILSFULL NAMERELATIONSHIPTELEPHONE (M)(H)(W)EMAIL ADDRESSWHAT ARE YOUR PRIMARY SKIN CONCERNS THAT YOU WISH TO BE TREATED WITH DERMAPEN™?DO YOU HAVE ANY KNOWN ALLERGIES?(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?Papulopustular rosaceaAcne vulgaris stage III-IVHerpes simplexDermatomyositisWartsSclerodermaPemphigus/pemphigoidBacterial/fungal InfectionsOpen lesionsSolar keratosisSkin cancerOtherHAVE YOU EVER EXPERIENCED ANY ADVERSE REACTION TO ANY FORM OF ANAESTHETIC?ARE YOU CURRENTLY UNDER MEDICAL SUPERVISION FOR ANY OF THE FOLLOWING?Cardiac conditions/ arrhythmiaAuto-immune disorderHaemophiliaHepatic diseaseDiabetes (type I or II)CancerHuman Immunodeficiency Virus (HIV)Pseudo cholinesterase deficiencyCongenial or idiopathic methemoglobinemiaARE YOU CURRENTLY PREGNANT OR BREASTFEEDING?ARE YOU CURRENTLY TAKING (OR HAVE TAKEN IN THE LAST 3 MONTHS) ANY OF THE FOLLOWING MEDICATIONS OR SUPPLEMENTS?Isotretinoin (including but not limited to Roaccutane®/ Accutane®/Isotane®)Anti-coagulants/blood thinners (including but not limited to Warfarin or aspirin)Photo-sensitisers (including but not limited to anti-depressants/anti-anxieties/antibiotics)Contraceptive pillFish oils/plant oils/omega 3sginseng/gingko biloba/St John’s wortHAVE YOU HAD ANY OF THE FOLLOWING PROCEDURES IN THE LAST 2 WEEKS ON THE AREA TO BE TREATED WITH DERMAPEN?Plastic/Cosmetic surgeryMuscle relaxant/wrinkle reduction injections (including but not limited to Botox®or Dysport™ or Xeomin®)Dermal Fillers (including but not limited to Juvederm®, Restylane®, Belotero®, Captique® Esthelis®, Radiesse®, Aquamid®,Sculptra® or Artefill®)MicrodermabrasionChemical peel (including but not limited to glycolic acid, lactic acid, mandelic acid or salicylic acid)Derma blading/derma planingLaser/IPL rejuvenation/hair removalRadio Frequency (RF) skin tighteningPhoto dynamic therapy (PDT)DermabrasionDeep chemical peelTattooing/cosmetic tattooingElectrolysis/diathermyHair removal (including but not limited to waxing, sugaring, plucking, threading or depilatory cream)Spray/self-tanningHAVE YOU USED ANY PRODUCTS CONTAINING ANY OF THE FOLLOWING INGREDIENTS ON THE AREA TO BE TREATED WITH DERMAPEN™ IN THE LAST WEEK?Alpha/beta hydroxy acids (including but not limited to glycolic acid, lactic acid or salicylic acid)Retinoids (Vitamin A) (including but not limited to tretinoin, retinol or retinaldehyde)Benzoyl peroxide/adapelene (Differin®)Hydroquinone/azelaic acid Brand/Hydroquinone/azelaic acid Brand/Product detailsCONSENTNameI 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.Patient SignatureStart signing your signature hereYour browser does not support e-Signature field.Dermapen™ practitioner signatureStart signing your signature hereYour browser does not support e-Signature field.DateI accept that any treatment I have taken is at my own risk. I certify that i have read and completed the above to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect, unknown because of this to which I accept full liability/responsibility I fully understand the above concent/permit and treatment/s to be carried out. The undertaken of the treatment/s has been fully explained to me. I accept full responsibility for this and or other complications which may arise or result during or following any procedure that is performed at my request.Your browser does not support e-Signature field.Submit
