New Client Consultation Form

Microneedling Consultation Form
Name*

First NameLast Name
Date*

MonthDayYear
Date of Birth*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*

Area CodePhone Number
E-mail*
example@example.com
Occupation *
Your Skin
What are your skin care goals?*

Acne FreeWrinkle FreeBrighterYounger Looking
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when?
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Your Health
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
If you checked YES to any of these please provide further information. If not mark, NA*
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsSteel/NickelOtherNone
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used
Are you an insulin dependant diabetic?

YesNo
Do you have active shingles?

YesNo
Are you haemophiliac?

YesNo
Are you taking blood thinning medication?

YesNo
FEMALE CLIENTS
Are you taking oral contraception?

YesNoN/A
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
Photograph and Video Release Form
I hereby grant and authorize The Beauty Room LLC right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites and other print or digital communications without payment or any other consideration.This authorization extends to all languages, media, formats, and markets now known or later discovered.I waive the right to inspect or approve the finished product wherein my likeness appears, including written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.I hereby hold harmless and release The Beauty Room LLC from all liability, petitions, and causes of action which I, my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate.Permissions granted for the pictures, video, and/or audio listed below:Initials*
Treatment
Pre-treatment: Do not exfoliate for 24 hours. No facial treatments 7 days prior. Avoid sun exposure/burns 24 hours prior to treatment. Discontinue use of retinoids 12 hours prior. Allow 12 hours after autoimmune therapies before treatment. Wait 6 months following isotretinoin use. Wait 14 days after botox/filler treatment. After-care: Avoid direct sunlight exposure, swimming, sauna, sun beds for 7 days following the treatment. If sun exposure cannot be avoided apply Sunscreen (SPF 30+) and wear for a minimum of 7 days. No facial treatments, botox/fillers for 14 days after treatment. Keep area clean and dry for 24 hours. No heat treatments or showers for 24 hours. Do not shave face for 3 days. No perfume or aftershave for 7 days. Do not cleanse the face for 3 days Avoid alcohol for 24 hours. Drink plenty of water. Do not touch the treatment area for 6-8 hours. Change pillow cases often. Avoid sweating excessively. No ibuprofen for 24 hours. Skin may be red, slight swelling, sensitive, itchy following treatment however, this will subside significantly in 24 hours and fully heal within 5 days. Mineral makeup can be used 72 hours after treatment. Side effects: Side effects are rare however, they can occur and include Allergic reaction to steel or serums used Robust inflammation of treated area Persistent itching Cutaneous eruption Reactivation of pre-existing HSV*

I have read the pre-treatment instructions and agree to adhere to themI have read the After-care instructions and agree to adhere to themI have read and understood the side effects and agree to treatment
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.

I have read and understood
Signature*

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Microneedling Consultation Form

Your Skin

Your Health

Photograph and Video Release Form

Treatment