Microneedling Consultation Form

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.
Full Name *

First Last
E-mail *
We will never SPAM or sell email addresses to third parties.
Phone: *
ex. 555-555-5555
Birthdate: *
ex. 01/05/1960
What is the best way to contact you? *

Phone call Email Text All
Do you have any permanent cosmetics or tattoos on the areas being treated? *

NO YES
Have you had any of these health conditions in the past or present? *

Cancer Hormone imbalance Systemic disease Highblood pressure Spinal injury Thyroid condition Hysterectomy Diabetes Heart problem Varicose veins Arthritis Asthma Eczema Epilepsy Fever blisters Hepatitis Herpes Cold sores Immune disorders HIV/AIDS Lupus Metal implants Phlebitis Blood clots Insomnia Seizure disorder Keloid scarring Migranes Skin disease Active Infection 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? *

Retin-A Renova Adapalene Differin Glycolic Acid AHA Retinol Accutane RoAccutane Microneedling At home laser Chemical Peels Permanent Makeup Laser Hair Removal Botox Fillers Tretinoin
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? *

NO YES
If yes, please explain:
Have you ever had an ALLERGIC reaction to any of the following? *

AHA's Retinoid Cosmetics Medicine Food Animals / Insects Sunscreens Iodine Pollen Fragrance Shellfish Latex Topical RX NONE
List any allergies you have had or currently have: *
Are you pregnant or trying to become pregnant? *

NO YES
Are you lactating? *

NO YES
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? *

YES NO
What conditions would you like to improve? *

Acne Oily Skin Dry Skin Bumps Large Pores Melasma Redness Brown Spots Sun Damage Milia Sagging Skin Rosacea Lines & Wrinkles Healthy Aging White spots Scarring Age Management Keratosis Pilaris Hyperpigmentation
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. *

I understand.
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.
Date *

Month Day Year
Signature *
Should be Empty:

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