DPW ATP Form Informed Consent Media Release As part of your DermapenWorld treatment program (Dermapen treatment or Dp Dermaceuticals) we will be photographing the treatment area of your body/face (and in some cases, filming) the treatment process. This will allow us to visually monitor your individual progress and see the results of your treatment over time. We would appreciate your willingness to share your outcomes and results with others, for both training and marketing purposes within the beauty, cosmetic and aesthetic industry. We will use absolute confidentiality regarding your identity when using your pictures. To confirm acceptance of this agreement, kindly sign the consent form below. Also we would be grateful if you could provide a comment as to how you felt about using the proposed treatment program and the results achieved in the space belowPatient *I consent to my before and after images from the treatment program being used for publicity through the media or promotions. I understand you will use absolute discretion in respect to my identityTreatment Provider *I consent to the attached ‘before and after images’ from a DermapenWorld treatment program provided by myself or treatment providers of our organisation Practice Beauty Clinic being used. I understand you will use absolute discretion in respect to the identity of our client. I understand you will credit these images to our organisation with the following informationClinic Name/Treatment ProviderHow many Dermapen treatments (with what intervals)Products used in treatmentProducts used at homecareWith this consent, I give permission for the images/footage (if they are selected) to be used in the following and similar materials: (Please tick one or both preferences)In training purposes: educational material for the clinics, DermapenWorld and its authorised representatives and internal use only, such as user/product manuals, educational charts and industry communications, training presentationsMarketing and advertising: may be used on company websites, social platforms or in-clinic waiting room materials or other such industry media channels. Examples are product/treatment brochures, clinic advertising material and information made available to other clients interested in the treatment.I, the undersigned, give my full consent for all photographs/footage captured before, during and after my DermapenWorld treatment program, allowing these images to remain the property of and be used by DermapenWorld and or its authorised representatives and hereby agree that my photograph and/or video image may be used as described above.Patient's SignatureYour browser does not support e-Signature field.DatePatient's NameATP's SignatureYour browser does not support e-Signature field.DateATP's NameTreatment ofComments/TestimonyI 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
