Microneedling Consent

Allana Davis Studio

Microneedling Consent
Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your main areas of concern that you wish to improve with Micro-needling?
Do you currently have, or have you previously been diagnosed with, cancer?
If yes, please specify the type of cancer, date of diagnosis, treatment received, and whether you have been medically cleared for cosmetic procedures.
History of raised or hypertrophic scarring
Have you ever developed a thick, raised or abnormal scar after surgery, injury, piercing, tattoo, acne or another skin procedure?
Have any of these scars been medically diagnosed as a keloid?
Please describe where it occurred, what caused it and whether medical treatment was required
I have disclosed my complete history of raised, hypertrophic, or keloid scarring, including scars resulting from surgery, injury, tattoos, piercings, acne, or cosmetic procedures. I understand that individuals with a history of abnormal scarring may have an increased risk of delayed healing, pigment changes, or abnormal scar formation following microneedling. I understand that treatment may be modified, postponed, or declined based on my medical history, skin assessment, and professional clinical judgment.
I have read and understood the acknowledgement above.
Have you ever experienced persistent darkening (hyperpigmentation) or lightening (hypopigmentation) of the skin following acne, injury, burns, laser treatments or cosmetic procedures?
Please check off any of the following conditions that apply to you.
Have you had any of the following within the past 2 weeks?
Do you have a history of cold sores (Herpes Simplex Virus)?
Are you currently taking antiviral medication?
Date of last outbreak:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other medical conditions, allergies or concerns not listed above:
I understand that completion of this consent form does not guarantee treatment. My suitability for microneedling will be determined following review of my medical history, skin assessment, and professional clinical judgment. Treatment may be modified, postponed, or declined if proceeding is not considered appropriate or safe.
By signing I certify that the information provided above is true and complete to the best of my knowledge. I understand that withholding relevant medical information may increase the risk of complications and may affect my suitability for treatment.

I understand that I have an ongoing responsibility to inform Allana Davis Studio of any changes to my medical history, medications, pregnancy status, or skin condition before each treatment.
Signature
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Allana Davis Studio

History of raised or hypertrophic scarring