Client Consent Form - Dermapen

Dermapen - Consent Form

Please read carefully and fill out the following form to help us understand your suitability for treatment

Are you experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell?
Have you travelled internationally within the last 14 days?
Have you or any of your household members been diagnosed with COVID-19 WITHIN THE PAST 30 DAYS?
Do you have any important personal engagements in the next week?
Do you have any known allergies? e.g. Latex, Shellfish, Nuts, Anaesthetic Agents, P- Aminobenzoic Acid (PABA), Sulphonamide Allergies etc
Are you currently experiencing any of the following skin conditions? Papulopustular rosacea, Acne vulgaris stage III­IV, Herpes simplex, Dermatomyositis, Warts, Scleroderma, Pemphigus/pemphigoid, Bacterial/fungal Infections, Open lesions, Solar keratosis, Skin cancer, Hemophilia, Pregnancy
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, Diabetes (I or II), Cancer, Congenial or idiopathic ethemoglobinemia, Pseudo cholinesterase, AIDS / HIV
Are you pregnant, breast feeding, or trying to conceive?
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*/Isotane*), Anti-coagulants/blood thinners (including but not limited to Warfarin or aspirin), Photo-sensitisers (including but not limited to anti-depressants/anti-anxieties/antibiotics), Contraceptive pill,
Have you had any of the following procedures in the last two weeks on the area to be treated with Dermapen? Plastic/cosmetic surgery, Muscle relaxant/wrinkle injections (including but not limited to Botox, Dysport or Xeomin, Dermal Fillers (including but not limited to Juvederm, Restylane, Belotero, Captique, Esthelis, Radiesse, Aquamid, Sculptra or Artefill), Microdermabrasion,
Do you have have any pre-existing medical conditions or have any questions regarding your treatment, if so please contact your GP prior to your treatment to discuss your suitability for treatment?
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Thanks for submitting!

CLINIC ADDRESS

Your treatment is at 116 Spring St, Bondi Junction (note: there is close parking in Westfields Mall or Eastgate Shopping Centre)

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