Name *

First Name

Last Name

Date of Birth *

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I have been advised that the object of the procedure I have requested is improvement in appearance, not perfection. It is possible for imperfections to persist, and that the result might not live up to my expectations or goals. I fully understand that the service provider cannot guarantee results. I acknowledge that no written or implied verbal guarantee, warranty, or assurance has been made to me regarding the outcome of the procedure that I herein requested and authorized. I also understand the limitations of thisprocedure. *

I understand the complications of theeDermaStamp Treatment to be as follows:

I understand the complications of theeDermaStamp Treatment to be as follows:

Erythema: The skin may remain red for generally 24 hours up to four days after eDermaStamp treatment. As the skin heals the erythema will resolve

I understand that a eDermaStamp can be combined with the application of serums, nutritional factors, and vitamins to stimulate optimal collagen production

I understand bruising may occur as a result of treatment

Hyper-pigmentation: A small number of patients may experience a hyper-pigmentation of the skin surface (especially if the skin is exposed to the sun)

I understand that in order to avoid possible adverse reactions I need to refrain from any intensive sun exposure and/or solarium for a period of 2 weeks. I shall use a sun block with a protection factor of 15 or higher

I understand that in order avoid possible adverse reactions I also need to refrain from any exercise following the treatment for a period of 24 hours

I shall follow the prescribed post procedure skin care to avoid infection

I understand that the post-treatment care regime is done with designated Dermaroller products which were specifically formulated for the treatment

I understand that I may require additional treatments in order to achieve maximum results and that some imperfections are not amenable to a eDermaStamp treatment

I understand that prior to treatment I must provide the treating clinician with any information regarding my former skin conditions and illnesses, including personal history of herpes simplex

I understand that patients with a history of herpes simplex (cold sores) may experience a flare up of the disease

I understand that infection is a rare possibility

I hereby give permission for photographs of the intended treatment site for diagnostic purposes and to enhance the medical record. I agree that these photographs will remain the clinic’s property. I further authorize to use these photographs for marketing purposes. It is specifically understood that in any such publication or use, I shall not be identifiable

I agree to follow the instructions given to me by the clinic to the best of my ability before, during, and after the procedure. I understand that patient responsibility and proper performance of the post-treatment care are critical to the success of the treatment. I have thoroughly read and understand the instructions and reviewed them with the treatment provider. I acknowledge that I have read and filled out the patient registration and medical history form fully and correctly to the best of my knowledge, and that the information that I have supplied is correct.

Do any of the following conditions apply to you?

Please indicate if any

Under 18 years of age.

Pregnancy or nursing.

Current or history of cancer, especially skin cancer, or pre-malignant moles.

Any active condition in the treatment area such as sores, active pustular acne, rosacea, keloid or raised scars, septic conditions, psoriasis, eczema and rash as well as irritated or damaged skin due to excessive fresh tanning.

Any active bacterial, viral or fungal infections

Vascular disorders such as: un-controlled diabetes, nervous diseases, cardiac disorder and cancer. In such cases, consult the treating physician.

Any recent use of products such as Accutane or Retin A.

Taking blood pressure, blood thinning or heart medications.

Actinic (solar) keratosis - Immunosuppression

Consent *

I don’t have a sunburn

I have not used any prescription retinoids (Tretinoin, Retin-A etc.) within 7 days

I have not used at-home exfoliants within 7 days

I have not waxed, threaded or any other form of hair removal for 7 days

I have not shaved 24 hours prior to today

I have not extended sun exposure within 10 days

I have not received a professional facial treatments within 2 weeks

I have not received botox/fillers/injectibles within 3 weeks

I have not gone under cosmetic Surgery within 12 weeks

I have not used Accutane within last 12 months

I am not pregnant, lactating or trying to become pregnant

Post Treatmet *

Day of treatment, skin will be tight and sensitive, similar to a mild sunburn. Redness should diminish within 24 to 72 hours Bruising and/or flaking may occur with some patients and will resolve

I will sleep on a fresh pillowcase and avoid touching face unnecessarily

I will ensure hands are clean if touching face

I will ONLY use approved skincare outlined by aesthetician for 7 days post-treatment. Product absorption increases from 7% to 80% post-needling. Unapproved skincare may lead to irritation, granulomas, and infection

I will not wear makeup for 48 hours, or only 100% mineral makeup after 24 hours

I will avoid excessive physical activity and sweating for 24 hours

I will not use hot tubs/saunas/swimming/hot showers for 48 hours

I will avoid waxing, threading or any other form of hair removal for 7 days

I will avoid prolonged sun exposure for 10 days

I wil not use at-home exfoliants for 14 days

I will not get professional facial treatments for 2 weeks

Date *

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