Derma pen is a skin needling procedure that uses 12 surgical grade micro-needles to piece the skin and
initiate the skin’s own healing mechanisms. It is used to treat wrinkles, scars, stretch marks, and other skin
conditions. The procedure requires multiple sequential treatments.
Following your treatment, you may experience, redness, petechiae (broken blood vessels that look like red
dots), stinging, itching, warmth, tightness of skin, skin dryness, and minor skin flaking. These should all
resolve within 4-5 days post-treatment.
Risks of this procedure include, but are not limited to, the following:
Pain –
Some people experience pain with this treatment. Stinging or sharp pain may be present during
and after the procedure. It can continue through the healing process until approximately 5 days.
Itching –
Patients can experience itching during the procedure as well as throughout the healing process.
Swelling –
Swelling can occur and last for 4-5 days.
Bleeding/Bruising –
You may experience some pinpoint bleeding which will probably stop within a few
minutes without any lasting effect. You may have residual red dots or petechiae from broken blood
vessels. These will resolve without treatment. Scabbing – A scab may be present if pinpoint bleeding occurs. The scabbing will disappear during the
natural wound healing process of the skin. Scarring or discoloration may result from any scab formation.
Allergic Reaction to Topical Numbing Cream – If you choose to have numbing cream applied, there is a
risk of allergic reaction which can include itching, burning, excessive redness, and swelling. If this
happens you should notify the office immediately. Flare of Herpes Simplex (Cold Sores) – Trauma to the area induced by the Derma pen can trigger a flare
of HSV or cold sores. If you have a history of cold sores, you should alert your treating provider and we
will give you a dose of antiviral medication to prevent this from happening. Bacterial Infection – This procedure involves piercing the skin with needles that create open channels.
There is a rare risk of bacterial infection. If you notice yellow crusting after the procedure or pus
drainage, you should call the office immediately. Any infection could last 7-10 days and could lead to
scarring. Failure to Achieve Desired Results – It is very possible that this procedure may fail to achieve your
desired results. Strict adherence to the pre-op and post-op instructions is essential.
Consent
Patient Name:
I, undersigned, have read and understand the information contained within this consent form. My
signature indicates that I have read and understand the information in the consent. I hereby release the
. and my provider from all liability associated with this procedure. Furthermore,
my signature below indicates my consent to the treatment described and my agreement to comply with
the requirements placed on me by this consent form.
I understand and agree that I am financially responsible for the payment I made for
that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the
date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months
period. I agree that my payment made is non-refundable or non-transferable post this period.
I declare that I have read and fully understood all points in this consent and that all of my questions were
answered to my satisfaction and I take the full responsibility of my decision in this consent.
Patient Name & Signature :
Doctor/Therapist Name & Signature :
Witness Name & Signature :
Parent or Gaurdian Name (if patient is minor) :
Date :
Consent to be photographed and published
I, , consent to be photographed and published on Social
media, by while before and after the procedure. I further authorize that the
photographs may be published for any purpose and in any form.
