Microneedling Consultation Form
Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
We will never SPAM or sell email addresses to third parties.
What is the best way to contact you?
Do you have any permanent cosmetics or tattoos on the areas being treated?
Have you had any of these health conditions in the past or present?
None of the above
After your treatment you will need to avoid working out, heavy sweating, steam rooms and/or saunas for at least 24 hours.
Walking and drinking lots of water are encouraged as they are both benefical in gently flushing the skin of cellular waste that may be released during your treatment.
List all medications you are currently taking, including any supplements:
Do you currently use any of the following products or have had treatments done?
At home laser
Laser Hair Removal
I understand that I must discontinue use of ALL of the above 5 days prior to treatment. Accutane or Roaccutane must be discontinued 1 year prior to treatment.
YES, I will discontinue.
Do you currently have any rash, windburn, sunburn, sensitivites or other issues on the area being treated?
If yes, please explain:
Have you ever had an ALLERGIC reaction to any of the following?
Animals / Insects
List any allergies you have had or currently have:
Are you pregnant or trying to become pregnant?
Are you lactating?
Skin Care History
When washing my face:
I use hot water
I use warm water
I use cool or cold water
How often do you use a skin regimen?
1x per day
2x per day
I do not use a regimen
Do you have an aversion to hot or cold tempuratures used on your face?
What conditions would you like to improve?
Lines & Wrinkles
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. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Helium Salon and/or the skin care professional from liability and assume full responsibility thereof.
To cancel an appointment please contact Helium Salon at least 24 hours prior to your appointment. Cancellations within 24 hours may be charged a fee of 50% of the total service cost.
I understand the cancellation policy.
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