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COSMED LASER SPA 

DERMAPEN

I do understand the cancellations and rescheduling policy and agree to pay the appropriate fees if I do not cancel or reschedule within 24 hours of my appointment date and time.

I do understand that taxes and gratuities are not included in any service I purchased. It is common practice to tip 15-20 % of the original service price. Please feel free to extend a gratuity as a result of your experience. Gratuities are accepted in the form of cash or credit card.

Dermapen is a skin needling procedure that uses 12 surgical grade micro-needles to piece the skin and initiate the skin’s own healing mechanisms. It is used to treat wrinkles, scars, stretch marks, and other skin conditions.

The procedure requires multiple sequential treatments.

Following your treatment, you may experience, redness, petechiae (broken blood vessels that look like red dots), stinging, itching, warmth, tightness of skin, skin dryness, and minor skin flaking.

These should all resolve within 4-5 days post-treatment.

 

CLIENT CONSENT FORM  

Risks of this procedure include, but are not limited to, the following:

Pain – Some people experience pain with this treatment. Stinging or sharp pain may be present during and after the procedure. It can continue through the healing process until approximately 5 days.

Itching – Patients can experience itching during the procedure as well as throughout the healing process.

Swelling – Swelling can occur and last for 4-5 days.

Bleeding/Bruising – You may experience some pinpoint bleeding which will probably stop within a few minutes without any lasting effect. You may have residual red dots or petechiae from broken blood vessels. These will resolve without treatment.

Scabbing – A scab may be present if pinpoint bleeding occurs. The scabbing will disappear during the natural wound healing process of the skin. Scarring or discoloration may results from any scab formation.

Allergic Reaction to Topical Numbing Cream – If you choose to have numbing cream applied, there is a risk of allergic reaction which can include itching, burning, excessive redness, and swelling. If this happens you should notify the office immediately.

Flare of Herpes Simplex (Cold Sores) – Trauma to the area induced by the Dermapen can trigger a flare of HSV or cold sores. If you have a history of cold sores you should alert your treating provider and we will give you a dose of antiviral medication to prevent this from happening.

Bacterial Infection – This procedure involves piercing the skin with needles that create open channels. There is a rare risk of bacterial infection. If you notice yellow crusting after the procedure or pus drainage, you should call the office immediately. Any infection could last 7-10 days and could lead to scarring.

Failure to Achieve Desired Results – It is very possible that this procedure may fail to achieve your desired results. Strict adherence to the pre-op and post-op instructions is essential. Multiple sequential treatments are required for maximum benefit.

I, undersigned, have read and understand the information contained within this consent form.

My signature indicates that I have read and understand the information in the consent.

I hereby release the BHSkin Dermatology and my provider from all liability associated with this procedure.

Furthermore, my signature below indicates my consent to the treatment described and my agreement to comply with the requirements placed on me by this consent form.

 

 

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


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Second Client's Name

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Last Name*
Second Client's Date of Birth*
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Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


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Third Client's Name

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Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


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Fourth Client's Name

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Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


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Fifth Client's Name

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Fifth Client's Date of Birth*
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Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


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Sixth Client's Name

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Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


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Seventh Client's Name

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Seventh Client's Date of Birth*
Seventh Client's Information
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No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


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Eighth Client's Name

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Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


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Ninth Client's Name

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No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


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Tenth Client's Name

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Tenth Client's Date of Birth*
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Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Parent or Guardian's Signature*
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By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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