DERMAL ROLLING / DERMA PEN / DERMA STAMP CONSENT FORM

For all Skin and Facial Needling Patients:

General Information: The concept of Skin Needling is based on the skin’s natural ability
to repair itself whenever it encounters physical damage such as cuts, burns and other
abrasions. Immediately after an injury to the skin our body reuses the damaged collagen
and elastin fibers as well as other damaged skin components to produce new ones. Skin
Needling allows for controlled induction of the skin’s self-repair mechanism by creating
micro- “injuries” in the skin which triggers new collagen synthesis. The result is smoother,
firmer and younger looking skin. Dermal needling is a process carried out with a roller that
is covered with numerous tiny needles. These needles penetrate the upper layers of skin
to a depth of 0.5mm or 1.0mm. this process has two major benefits. It effectively
stimulates collagen formation at the same time as providing a clear channel for topical
serums / active ingredients in your skin care to be absorbed more effectively through the
top layer (epidermis) of skin. Dermal Rolling / Derma Pen / Derma Stamping creates a
very minor (almost microscopic) trauma which lasts for a short period of time. Skin
Needling is a form of Collagen Induction Therapy which is intended to smooth wrinkles,
and improve depressed acne scarring.

It makes pin point punctures into the dermis. Your body perceives this as damage, which
triggers the release of growth factors that, in turn, stimulate the production of elastin and
collagen. The human body is designed to react to any injury by initiating the healing
process, but usually it will just mend as far as it has to keep you in good health – which is
very different to healing to a cosmetic level. By persistently triggering this healing
process, you encourage your body to keep repairing until the job is done. It may be
conducted safely on all colors of skin and all types of skin.

You are eligible for Dermal Rolling / Derma Pen / Derma stamping  if the following
applies to you: -Lack of skin radiance -Loss of elasticity and epidermal thickness – Rough
and uneven skin texture – Fine lines – Wrinkles – Crow’s feet – Hyperpigmentation –
Scars, especially intended acne or chicken pox – Post surgical scars- Skin dullness – Dry
skin – Pre cosmetic surgery – Pre injection – Open pores

You are not eligible for Dermal Rolling / Derma Pen / Derma stamping  if the
following applies to you: - You suffer with active pustular acne – Active bacterial, viral or
fungal infections – Eczema and psoriasis – rosacea – Keloid or raised scars – Scars less
than 6months old – Raised moles or warts – Facial surgery in the past 6 months –
Patients taking blood thinning or heart medications – Diabetes – Actinic (solar) keratosis –
Immunosuppression.

By Signing this form, You consent and confirm to the following:

1. I consent that I do not suffer from any of the above contraindications listed. I
understand that my skin will be flushed and red and may experience redness and
warmth after the treatment.
2. I understand that the number of Dermal roller treatments required may vary and
that several treatments will need to be performed to achieve the desired results. I
understand that there may be some degree of minor discomfort, i.e.: itchiness,
irritation and stinging, skin may feel hot, bruising, scarring, crusting, redness,
 infection, onset of herpes, onset of acne, burning and blistering, unsatisfactory
cosmetic result, extrusion, swelling, transient skin discoloration and allergic
reaction which can last up to 4-5days post treatment.
3. I understand that there is no guarantee to this procedure and in order to achieve
the maximum long-term results, I will need maintenance treatments and need to
follow the guidance of correct after care advice recommended by my therapist.
Picking the area may result in adverse reactions and affect the results of the
treatments thereby strictly prohibited.
4. I understand that exposure of a recently treated area to strong sunlight should be
avoided and I should use sunblock of SPF30 minimum.
5. I have confirmed that I have informed the therapist of all medical details relevant
to this treatment and will update these throughout the course of the treatment
should any details change.
6. I have confirmed that I understand all the information given regarding this
treatment during the consultation and that all my questions have been answered
satisfactorily.

I certify that I have read and fully understand this Consent/Procedure Form, the
explanations referred to me were in fact made to me and the form was filled prior to
commencement of treatment.

I agree that if I should have any questions or concerns regarding my treatment/results I

will notify immediately so that timely follow-up and intervention can be provided.

Having been apprised of all the above, I have signed this Consent Form and authorize the
subject treatment.

Patient Name & Signature: ______________________Date&Time:___________

Therapist Name & Signature: _____________________Date&Time:__________

Translator Name & Signature: ____________________Date&Time:___________