DP4 CONSENT | HYRBID BEAUTY INC.

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PRE + POST TREATMENT

CIRCADIA FORMS

Informed Consent for Dp4TM treatment at

THE HYBRID BEAUTY LOUNGE

CURRENT DATE*

Month

Day

Year

Dp4 CLINIC

PRACTITIONER

PATIENT DETAILS

First name*

Last name*

Birthday*

Month

Day

Year

Address*

Phone*

Email*

WHAT ARE YOUR PRIMARY SKIN CONCERNS THAT YOU WISH TO BE TREATED WITH Dp4?*

Feel free to include any/all photos or videos of your primary skin concerns

DO YOU HAVE ANY KNOWN ALLERGIES? (Eg. latex, metals, shellfish, nuts, penicillin, anaesthetic agents, P-aminobenzoic acid [PABA], sulphonamide allergies.)

Yes

ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING ACTIVE SKIN CONDITIONS?

Papulopustular rosacea

Acne vulgaris stage III-IV

Herpes simplex

Dermatomyositis

Warts

Scleroderma

Pemphigus/pemphigoid

Bacterial/fungal Infections

Open lesions

Solar keratosis

Skin cancer

Psoriasis

Undiagnosed / unusual moles

Lupus erythematosus

Collagen vascular diseases

Vitiligo

Keloid scars

Other

HAVE YOU EVER EXPERIENCED ANY ADVERSE REACTION TO ANY FORM OF ANAESTHETIC?*

Yes

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?

Pregnant

Breastfeeding

ARE YOU CURRENTLY TAKING (OR HAVE TAKEN IN THE LAST 3 MONTHS) ANY OF THE FOLLOWING MEDICATIONS OR SUPPLEMENTS? (Please tick.)

Isotretinoin (including but not limited to Roaccutane®/Accutane®/Isotane®)

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 wort

HAVE YOU HAD ANY OF THE FOLLOWING PROCEDURES IN THE LAST 2 WEEKS ON THE AREA TO BE TREATED WITH Dp4TM? (Please tick.)

Plastic/cosmetic surgery

Botulinum toxin/BTX/muscle relaxant/wrinkle reduction injections (including but not limited to Botox®/Vistabel®, Dysport™/Azzalure™ Xeomin®/ Bocouture®)

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

Dermal fillers (including but not limited to Juvederm®, Restylane®, Teosyal®, Princess®, Stylage®, Esthelis®, Radiesse®, Belotero®, Captique®)

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 Dp4TM IN THE LAST WEEK? (Please tick.)

Resurfacing agents (including but not limited to alpha-hydroxy-acids, salicylic acid)

Retinoids/retinoid-like agents (including but not limited to tretinoin/retinoic acid, tazarotene, adapalene, retinol)

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:

Other:

CONSENT

I,*

, have completed the Dp4TM Treatment Consultation & Consent Form honestly and to the best of my knowledge. My Dp4TM Authorised Treatment has thoroughly explained to me:

• What a Dp4TM treatment is

• How a Dp4TM treatment works

• Expected outcomes of my Dp4TM treatment

• Dp4TM treatment contraindications and

considerations

• Anaesthesia protocols - pros and cons

• Post-op care with Dp DermaceuticalsTM

And I understand that a course of Dp4™ treatments will be required for optimum results

DATE*

Month

Day

Year

CLIENT NAME*

CLIENT SIGNATURE*

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Thank you for filling out our consent form! Please submit after completeing your e-signature.

TO BE FILLED OUT BY ATP

DATE

Month

Day

Year

Dp4TM ATP NAME

Dp4TM ATP SIGNATURE

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