Dermapen 4 Skin Needling Consult Form Name * First Name Last Name Date of birth MM DD YYYY Are you currently experiencing any of the following with your skin? * Acne vulgaris (stage 3-4) Bacterial/fungal infections Dermatitis Herpes simplex Papulopustular rosacea Pemphlgus/pemphigold Open lesions Scleroderma Skin cancer Solar keratosis Warts NONE OF THE ABOVE OTHER Please specify if you have ticked 'OTHER' Are you under supervision for any of the following? * Auto-immune disorder Cancer Cardiac conditions/ Arrhythmia Congenial or idiopathic methemoglobinemia Diabetes (Type I or II) Haemophilia Hepatic disease Human immunodeficiency virus (HIV Pseudo cholinesterase deficiency NONE OF THE ABOVE OTHER Please specify if you have ticked 'OTHER' Are you currently taking (or have taken in the last 3 months) any of the following supplements? * Anti-coagulants/blood thinners (including but not limited to Warfarin or aspirin) Contraceptive pill Fish oils/plant oils/omega 3s Ginseng/gingko biloba/St John's wort Isotretinoin (including but not limited to Roaccutane/Accutane/Isotane) Photo-sensitisers (including but not limited to anti-depressants/anti-anxieties/antibiotics) NONE OF THE ABOVE In the last 2 weeks, have you had any of these treatments? * Only in relation to areas that will be treated with skin needling Anti-wrinkle injections (ie. Botox, Dysport etc.) Chemical Peel (ie. Glycolic acid, lactic acid, salicylic acid etc.) Dermabrasion (ie. Hydrodermabrasion, microdermabrasion) Derma blading/ Derma planing Electrolysis Fillers (ie. Juvederm, Restylane, Sculptra etc.) Hair removal (ie. Depilatory cream, plucking, sugaring, threading, waxing etc.) Laser/IPL Plastic/Cosmetic surgery Radio frequency (RF) Spray/self-tan Sun tan/solarium Tattoo/cosmetic tattoo NONE OF THE ABOVE In the last week, have you used any products containing any of the following ingredients? * Only in relation to areas that will be treated with skin needling AHA/BHA (ie. Glycolic acid, lactic acid, salicylic acid) Azelaic acid Benzoyl peroxide Hydroquinone Retinoids/Vitamin A (Adapalene, tretinoin, retinol) NONE OF THE ABOVE Do you have any known allergies? Food/liquids/materials/medication * (Eg. Latex, materials, shellfish, nuts, penicillin, anaesthetic agents, P-aminobenzoic acid (PABA), sulphonamide allergies) Consent to follow all pre/post care information * My treatment provider for Dermapen has provided me with all pre-treatment and post-treatment information, and has verbally explained to me all that entails for a skin needling treatment. I accept full responsibility for my pre and post care and understand that a course of Dermapen treatments are required for optimum results. Yes No Consent for treatment * I hereby have completed Dermal Edit's Skin consultation form and Skin Needling Consent form honestly and to the best of my knowledge about myself, my skin and medical background. By signing this form, I understand all information given to me, give my consent for treatment and will alert of any future changes to my medical history. Today's date * MM DD YYYY Thank you!
