DermaRoller Consent Form 2011

CONSENT FORM
DERMAROLLER
Surname: ____________________________ First Name: ___________________________
Address: ______________________________________________________________________________
_____________________________________ Postcode: _____________________________
Tel No: ______________________________ Date of Birth: __________________________
Mobile Number: _______________________ Email: ________________________________
Profession: ___________________________ How did you hear about us: ______________
Expectations and Motivations: _____________________________________________________________
PATIENTS WHO SHOULD NOT BE TREATED:
_ Active cold sores or warts,

_ Skin with open wounds,
_ Sunburn,
_ Excessively sensitive skin,
_ Dermatitis
_ Inflammatory rosacea in the area to be treated.
_ Inform the esthetician if you have any history of herpes simplex.
_ History of allergies,
_ Rashes,
_ Other skin reactions,
_ Sensitive to any of the components of this treatment.
_ If you have taken Roaccutane within the past year,
_ Treated with chemotherapy or radiation therapy.
_ Keloid Scaring
ONE-WEEK BEFORE YOUR DERMAROLLER TREATMENT

Avoid these treatments for one entire week prior to your Dermaroller treatment:
Electrolysis
Waxing
Depilatory Creams
Laser Hair Removal
TWENTY-FOUR HOURS BEFORE YOUR TITANTIUM DERMAROLLER TREATMENT Stop using:
AHA or BHA, or benzyl peroxide
Any exfoliating products that may be drying or irritating
12 BEAUCHAMP
PLACE
London, SW3 1NQ
Tel: 0207 838 0765
www.cosmeticsurgerylondon.net
CONSENT FORM
DERMAROLLER
THE DAY OF YOUR DERMAROLLER

Cleanse your skin in the morning and do not apply makeup on face other than eyes and
lips.
AFTER YOUR DERMAROLLER TREATMENT

It is imperative that the health of your skin and the success of your treatment that these
guidelines be followed:
1. Do not use any AHA’s or BHA on your skin for 24hours
2. It is imperative that you use a sunscreen with an SPF of at least 30 and avoid direct sunlight for at
least 1 month.
3. Patients with hypersensitivity to the sun should take extra precautions to guard against exposure
immediately
following the procedure, as they may be more sensitive following the peel.
4. Your skin may be more red than usual for 2 hours.
5. Please avoid strenuous exercise during this time.
6. You may have some peeling or flaky skin for a few. days
7. DO NOT PICK OR PULL THE SKIN.
8. When washing your face, do not scrub. Use a gentle cleanser designed for Sensitive skins
9. Apply a light moisturiser as often as needed to relieve dryness and tightness.
10. Do not have any other facial treatment for at least one week after your Dermaroller treatment
Although the Dermaroller treatment is effective in most cases, no guarantee can be made that a
specific patient will benefit from the treatment.
The Dermaroller is recommended for Photodamaged skin; Rough texture; Aging skin; Photo-damaged
skin and
Hyperpigmentation
A consultation and skin evaluation by your skin care professional prior to your treatment is important.
Please read and sign the following:
PLEASE CONFIRM THAT YOU HAVE NONE OF THE FOLLOW - BEFORE AGREEING TO GO AHEAD
WITH THE PEEL
Pregnancy _ Yes _ No
Use of Roaccutane _ Yes _ No
Cold sores (Herpes outbreak) _ Yes _ No
Acne _ Yes _ No
Plastic surgery in last 6 months _ Yes _ No
Use of Retin A/Retinova/Retinol products _ Yes _ No
Further Considerations for Consent
1) I acknowledge that no guarantee has been given to me as the condition of the complexion, skin pore
size, wrinkle reduction, or the amount or percentage of improvement expected following the treatment.
2) I acknowledge that for many conditions, more than one Dermaroller Treatment may be required in
certain areas to achieve the desired result. In fact, a course of a minimum of 6 is recommended for
best results.
3) I acknowledge that no guarantee or assurance has been made by anyone regarding the procedure
that I herein request and authorize.
4) If I know or suspect that I may be pregnant, I will inform the operator prior to treatment.
12 BEAUCHAMP
PLACE
London, SW3 1NQ
Tel: 0207 838 0765
CONSENT FORM
DERMAROLLER
By signing below, I acknowledge that I have read the foregoing informed consent regarding the
Dermaroller treatment and I feel I have been adequately informed regarding the associated risks. I
hereby give consent to the Dermaroller procedure to be performed by a Qualified Person
Treatment No 1 Date _______________ ____________________________ _______________________________

Patient Signature Practitioners Signature
Treatment No 2 Date _____________ ____________________________
_______________________________
Patient Signature Practitioners Signature
Treatment No 3 Date _______________ ____________________________
_______________________________
Patient Signature Practitioners signature
I agree to notify HB HEALTH CLINIC immediately if, in the unlikely event, I experience any of the possible side effects
that have been explained to me.
I understand and agree to the costs involved and payment is non-refundable. I will give 24 hours notification for
cancelling my appointment otherwise the missed session will be taken off from my account.
I give written consent to this further treatment and I understand the risks, benefits, possible side effects and
alternatives. I take the treatment at my own risk and I will not hold the employees of HB Health responsible for the
advice delivery or treatment.
Name: _________________________ Signed: ______________________ Date: _______________
12 BEAUCHAMP
PLACE
London, SW3 1NQ
Tel: 0207 838 0765

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CONSENT FORM

Surname: __ First Name: _

PATIENTS WHO SHOULD NOT BE TREATED:

_ Active cold sores or warts,

ONE-WEEK BEFORE YOUR DERMAROLLER TREATMENT

THE DAY OF YOUR DERMAROLLER

AFTER YOUR DERMAROLLER TREATMENT

Further Considerations for Consent

Treatment No 1 Date _ _________________

Name: _________ Signed: Date: _

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