Dermaroll Consultation and Consent Form | Beauty Forms Portal

Dermaroller Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Do you have any medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

Have you previously had Dermarolling? *

What are your reasons for having Dermarolling? *

Do you have any skin concerns? *

Please provide detail: *

Treatment Information

What is a dermaroller treatment?

A dermaroller is a titanium device that is rolled over the skin to create thousands of tiny contact points. It is a type of microneedling treatment that causes the body to create a wound healing process for rejuvenated, smoother and younger looking skin.

Who is dermaroller treatment good for?

Dermaroller treatment is good for clients who need a large area treated, and is most commonly used to treat the following skin conditions:

Dull skin: Rejuvenate tired and dull skin and combat the initial signs of ageing.
Wrinkles: Fine lines and wrinkles on the face can be visibly reduced, as dermarolling triggers collagen production.
Scarring: Scars from acne and Chicken Pox can be improved and an uneven texture can be smoothed out with dermarolling
Pigmentation: Can help to fade dark patches such as pigmentation due to sun damage or ageing. Dermaroller microneedling is a great treatment for you if you have darker skin because it doesn’t involve peels or lasers, which can cause pigmentation issues.

Aftercare Advice

During the first 48 hours, refrain from exercise, saunas, hot tubs, and sun-beds.
Avoid strong sunlight and do not use sunscreen (after 48 hours, use sunscreen everyday).
Avoid touching your treated skin unnecessarily. Always wash hands or use gloves before touching treated skin.
Avoid makeup for 24 hours. If you must use makeup within the first 24 hours, please only use a 100% pure mineral powder makeup.
For the first few days after your microneedling procedure, you’ll need to avoid any skin care product that contains harsh chemicals meant to exfoliate. Avoid anything that’s scented, and don’t use glycolic acid or alpha hydroxy acids.
Retinol A and vitamin C serum should be avoided for the first 48 hours, minimum, after microneedling. Once 2 full days have passed, you might want to gradually add products back into your daily beauty routine instead of doing your usual regimen, especially if you use products that have strong anti-aging formulas.
Be sure to run any cleansers, toners, or scrubs that you plan to apply in the 2 to 3 days after microneedling by your provider to make sure the ingredients won’t worsen side effects.
Hyaluronic acid can be used following microneedling, and it’s even recommended in some cases to help stimulate collagen production after your procedure.
If your skin is feeling dry, it’s generally safe to apply coconut oil as an emollient to lock in moisture and hydrate your face after microneedling. Diluted, alcohol-free witch hazel may also be used to cleanse dry skin. Stick to using gentle, natural ingredients that you’re familiar with.

Please tick the box to confirm: *

I have read and understood the aftercare advice.

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive the Dermaroller treatment.

Client Signature: *

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