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Lotus
@
QUEENSWAY MEDICAL
A Physician-Led Clinic
(416)-238-6773
1066 The Queensway, Etobicoke, ON M8Z 1P7
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Dermapen 4 Consent and Treatment
DERMAPEN 4TM TREATMENT
Date
Dermapen Clinic
Practitioner
First Name
Last Name
Birthday
Home Address
Email
Phone
Emergency Contact
First and Last Name
Relationship
What Are the Primary Concerns That You Wish To Be Treated With DERMAPEN4?
Do You Have Any Known Allergies?
Medical History:
ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING ACTIVE SKIN CONDITIONS?
Papulopustular rosacea
Acne vulgaris stage III-IV
Herpes simplex
Dermatomyositis
Pemphigus/pemphigoid
Bacterial/fungal Infections
Open lesions
Solar keratosis
Skin cancer
Undiagnosed / unusual moles
Lupus erythematosus
Collagen vascular diseases
Vitiligo
Keloid scars
Scleroderma
Psoriasis
Other
HAVE YOU EVER EXPERIENCED ANY ADVERSE REACTION TO ANY FORM OF ANAESTHETIC?
ARE YOU CURRENTLY UNDER MEDICAL SUPERVISION FOR ANY OF THE FOLLOWING?
Cardiac conditions/arrhythmia
Auto-immune disorder
Haemophilia
Hepatic disease
Human Immunodeficiency Virus (HIV)
Pseudo cholinesterase deficiency
Congenial or idiopathic methemoglobinemia
Diabetes (type I or II)
Cancer
Atopy/allergies
Other chronic illness
ARE YOU CURRENTLY PREGNANT OR BREASTFEEDING
Choose an option
ARE YOU CURRENTLY TAKING (OR HAVE TAKEN IN THE LAST 3 MONTHS) ANY OF THE FOLLOWING MEDICATIONS OR SUPPLEMENTS?
Isotretinoin (including but not limited to Roaccutane / Accutane/ lsotane)
Anti-coagulants/blood thinners (including but not limited to Warfarin, aspirin, or immunosuppressant medications)
Photo-sensitisers (including but not limited to anti-depressants/anti-anxieties/antibiotics)
Contraceptive pill
Fish oils/plant oils/omega 3s
Ginseng/gingko biloba/St John's wart
HAVE YOU HAD ANY OF THE FOLLOWING PROCEDURES IN THE LAST 2 WEEKS ON THE AREA TO BE TREATED WITH DERMAPEN 4?
Plastic/cosmetic surgery
Botulinum toxin/BTX/muscle relaxant/wrinkle reduction injections (including but not limited to Botox'/Vistaber, Dysport"/AzzalureTh Xeominl Bocouturel
Long-term/semi -permanent injectables (including but not limited to Aquamid, Sculptra, Artefill)
Microdermabrasion
Derma blading/derma planing
Laser/IPL rejuvenation/hair removal
Tattooing/cosmetic tattooing
Electrolysis/diathermy
Radio Frequency (RF) skin tightening
Derma; fillers (including but not limited to Juvederm', Restylane', Teosyal', Princess', Stylege', Esthelis', Radiesse', Belotero', Captiquel
Photo dynamic therapy (PDT)
Chemical peel (including but not limited to glycolic acid, lactic acid, mandelic acid or salicylic acid)
Dermabrasion
Deep chemical peel
Hair removal (including but not limited to waxing, sugaring, plucking, threading or depilatory cream)
Spray/self-tanning
HAVE YOU USED ANY PRODUCTS CONTAINING ANY OF THE FOLLOWING INGREDIENTS ON THE AREA TO BE TREATED WITH DERMAPEN 4T" IN THE LAST WEEK?
Resurfacing agents (including but not limited to alpha-hydroxy-acids, salicylic acid)
Retinoids/retinoid-like agents (including limited to tretinoin/retinoic acid, tazarotene, but not adapalene, retinal)
Antimicrobial agents (including but not limited to benzoyl peroxide, isopropyl alcohol)
Bleaching/depigmenting agents (including but not limited to Kligman's Formula, hydroquinone)
Brand/product details:
CONSENT
I have completed the Dermapen 4TM Treatment Consultation & Consent Form honestly and to the best of my knowledge. My Dermapen 4-" Authorised Treatment has thoroughly explained to me:
What a Dermapen 4 treatment is
How a Dermapen 4 treatment works
Expected outcomes of my Dermapen 4 treatment
Dermapen 4 treatment contraindications and considerations
Anaesthesia protocols - pros and cons
Post-op care with Dp Dermaceuticals
I understand that a course of Dermapen 4" treatments will be required for optimum results
Patient Signature
Clear
Today's date
Dermapen 4 ATP Signature
Clear
Signed date
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