Dermapen Clinical Treatment Consultation & Consent Form

Have 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/kojic acid/azelaic acid
I 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.
Signature

Title