DERMAPEN CLINICAL PATIENT FORM

DERMAPEN CLINICAL PATIENT

PRE-TREATMENT FORM
Dermapen™ is a corrective treatment that creates rejuvenating micro-channels into the skin's matrix. Employing patented technology, Dermapen's™ oscillating action effortlessly glides over the skin to initiate and stimulate the body's own natural healing and regenerative response. It is possible to achieve striking results by delivering a versatile and customized treatment, which has been documented to improve the appearance of aging, wrinkles, uneven skin tone, uneven texture, stretch marks and scar tissue on face and body areas. Dermapen™ treatments are fast, effective, comfortable and offer results after just one treatment. Based on your areas of concern, your Dermapen™ practitioner may recommend a series of treatment for optimal results. Your Dermapen™ clinical treatment only uses genuine Dermapen™ devices and is performed by a Dermapen™ qualified practitioner.

CONTRAINDICATIONS:

Dermapen™ treatments are not suitable for patients experiencing active:
- Papulopustular rosacea
- Acne vulgaris stage III-IV
- Herpes simplex
- Warts
- Scleroderma
- Bacterial/fungal infections
- Open lesions
- Solar keratosis
- Skin cancer
- Hemophilia
- Pregnancy (First Trimester)
PRECAUTIONS/CONSIDERATIONS:

Certain health conditions, medications, supplements and lifestyle factors may affect a Dermapen™ procedure. All patients are required to complete a Dermapen™ Consultation Form prior to any clinical treatment for assessment by a qualified Dermapen practitioner. If you are prone to herpes simplex (cold sores), it is recommended to take or apply a targeted prophylaxis, such as acyclovir, to prevent a possible outbreak. For tanned to dark complexions or skins prone to post-inflammatory hyper-pigmentation, it is recommended to use a melanin inhibiting skin regime for at least 2 weeks prior to a Dermapen™ clinical treatment. Dermapen™ recommends the twice daily application of DP Dermaceuticals Brite Lite™.

COMFORT:

Your Dermapen™ practitioner will take all steps to ensure total comfort for your Dermapen™ procedure. If at any point you feel discomfort, please inform your practitioner immediately. If you have any allergies or have had any past reaction to topical numbing cream or anesthetic, please inform your Dermapen™ practitioner prior to treatment.

HEALTH & SAFETY:

Your Dermapen™ treatment only uses sterile, single use consumables throughout the procedure, ensuring complete health and safety.

TREATMENT DURATION:

Please allow 45-90 minutes for your Dermapen™ clinical treatment including preparation, numbing and post-care.
DERMAPEN CLINICAL PATIENT

POST-TREATMENT INFORMATION
During the skin healing process, minor itching, hives, ﬂaking, or redness may appear. If symptoms persist, please call your Dermapen™ practitioner. Do not pick, squeeze or agitate during the recovery period. Please avoid the following activities for up to 2 days following a Dermapen™ clinical procedure:
- Direct ultra violet exposure (sun and solariums)
- Intensive cardio, exercise or gymnasium regimens
- Excessively hot showers, bathing, spas or sauna
- Spray or self-tanning
- Swimming in chlorinated pools or the ocean
- Tattooing (including cosmetic tattooing)
- Further clinical treatments (including, but not limited to): microdermabrasion, laser, intense pulsed light, chemical peels, muscle relaxant injections and dermal fillers) should be avoided for up to two weeks.
Please avoid the use of skin care products containing any of the following active resurfacing ingredients for up to 5 days following a Dermapen™ clinical procedure:
- Alpha hydroxy acids (AHAs) (including but not limited to) glycolic, lactic or malic acid
- Beta hydroxy acid (BHA) including salicylic acid
- Benzoyl peroxide
- Retinoids (including but not limited to) tretinoin, retinol and retinaldehyde
- Hydroquinone
- High levels of Kojic or azelaic acid
- Alcohol (including but not limited to) isopropyl alcohol/de-natured alcohol/rubbing alcohol
Your DP Dermaceuticals regimen may be altered by your practitioner, according to your individual needs and skin conditions.

Light, non-occlusive and non-comedogenic make-up may be applied 24 hours post-procedure. Dermapen™ recommends Cover Recover™ as a daily skin protectant and camouflage in one.

If in doubt with any of the above activities or products, please call your Dermapen™ practitioner for clarification to when normal activity or use may be resumed.
DERMAPEN TREATMENT

CONSULT & CONSENT FORM
DATE*

DayMonthYear
Date
DERMAPEN CLINIC
DERMAPEN PRACTITIONER*
PATIENT DETAILS
FULL NAME*
DATE OF BIRTH*

DayMonthYear
Date
ADDRESS*
TELEPHONE (M)
(MOBILE)*
Email*
example@example.com
EMERGENCY CONTACT DETAILS
FULL NAME*
RELATIONSHIP*
TELEPHONE (M)*
EMAIL ADDRESS*
example@example.com
WHAT ARE YOUR PRIMARY SKIN CONCERNS THAT YOU WISH TO BE TREATED WITH DERMAPEN?*
YesNo
DO YOU HAVE ANY KNOWN ALLERGIES? (PLEASE LIST BELOW) (E.G. LATEX, METALS, SHELLFISH, NUTS, PENICILLIN, ANAESTHETIC AGENTS, P AMINOBENZOIC ACID (PABA), SULPHONAMIDE ALLERGIES)*
Papulopustular rosaceaAcne vulgaris stage III-IVHerpes simplexDermatomyositisWartsSclerodermaPemphigus/pemphigoidBacterial/fungal InfectionsOpen lesionsSolar keratosisSkin cancerNone of the above
HAVE YOU EVER EXPERIENCED ANY ADVERSE REACTION TO ANY FORM OF ANAESTHETIC?*
YesNo
YesNo
Isotretinoin (including but not limited to Roaccutane®/Accutane®/Isotane®)Photo-sensitisers (including but not limited to anti-depressants/anti-anxieties/antibiotics)Contraceptive pillAnti-coagulants/blood thinners (including but not limited to Warfarin or aspirin)Fish oils/plant oils/omega 3sGinseng/gingko biloba/St Johnʼs wortNone of the above
Plastic/Cosmetic surgeryDerma blading/derma planingMuscle relaxant/wrinkle injectionsLaser/IPL rejuvenation/hair removalRadio Frequency (RF) skin tighteningPhoto dynamic therapy (PDT)Dermal Fillers including but not limited toDermabrasionDeep chemical peelTattooing/cosmetic tattooingMicrodermabrasionChemical peel (including but not limited to glycolic acid, lactic acid, mandelic acid or salicylic acid)Electrolysis/diathermyHair removal (including but not limited to waxing,sugaring, plucking, threading or depilatory cream)Spray/self-tanningNone of the above
Alpha/beta hydroxy acids (including but not limited to glycolic acid, lactic acid or salicylic acid)Benzoyl peroxide/adapelene (Diﬀerin®)Hydroquinone/kojic acid/azelaic acidRetinoids (Vitamin A) (including but not limited to tretinoin, retinol or retinaldehyde)None of the above
I, ...........(TYPE NAME BELOW)......., have completed the Dermapen™ Clinical Treatment Consultation & Consent Form honestly and to the best of my knowledge. My Dermapen™ practitioner 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 • Post-op care. *
I understand that a course of Dermapen™ clinical treatments will be required for optimum results.
Patient name*
Patient signature (SIGN BELOW)

Clear
Date Signed (by patient)*

DayMonthYear
Date
SECTION BELOW TO BE FILLED OUT BY PRACTITIONER, PLEASE GO TO "SUBMIT" AND THEY WILL COMPLETE LATER ON THEIR DEVICE
Practitioner name
FILL NAME IN CAPS
Practitioner signature

Clear
Date Signed (by practitioner)*

DayMonthYear
Date
Should be Empty:

DERMAPEN CLINICAL PATIENT

DERMAPEN CLINICAL PATIENT

DERMAPEN TREATMENT