Microneedling Consultation and Waiver Form

  • Microneedling Consultation & Consent Form

  • Personal/Medical History Form

    To provide you with microneedling treatment, please complete the following questionnaire. All information you provide will be kept strictly confidential.

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about us?*
  • Are you currently under the care of a physician for management of an illness or condition?*
  • Do you have any Botox or other injectables on the last 30 days?*
  • Have you ever had an allergic reaction to any food, drug or enviromental source?*
  • Are you pregnant or trying to become pregnant?*
  • Are you breastfeeding?*
  • Are you on any blood-thinning medications or immunosuppressive drugs, such as aspirin?*
  • Have you used Accutane or been treated for acne in the past year?*
  • Do you use skincare products with Retin-A, Retinols or Vitamin A?*
  • Do you have any known allergies to lidocaine, or numbing agents?*
  • Have you had a chemical peel or exfoliation treatment in the last 30 days?*
  • Do you have any known allergies to serums or ingredients used in microneedling treatments?*
  • Have you had any facial procedures done in the last 30 days?*
  • Are you currently using any products containing tretinoin, glycolic acid, salicylic acid, or other active ingredients?*
  • Do you have a history of, or currently experience, epilepsy or seizures?*
  • Rows
  • Do you have any other health problems or medical conditions not listed above?*
  • Have you had any recent medical procedures?*
  • Do you have any chronic medical conditions?*
  • Do you currently have any blemishes, cuts, irritation, or infections on the area to be treated?*
  • Do you have any moles, raised areas, prior or current in the projected procedural area?*
  • In the last 4 weeks have you had any dermal treatments such as tattoos, dermal fillers, piercings or botulinum toxin?*

  • Treatment Information

  • What is Microneedling?

    Microneedling is a minimally invasive cosmetic procedure that’s used to treat skin concerns via collagen production. Also known as collagen induction therapy, this treatment may help those looking to reduce the appearance of acne scars and stretch marks.

    It’s also used in certain anti-aging procedures, such as eyelid surgery and sun spots. Microneedling isn’t effective for hair loss, despite the possible role of collagen in hair growth.

    Microneedling works by encouraging your skin to make more collagen. The idea is that pinpricks from the procedure cause slight injury to the skin and that the skin responds by making new collagen-rich tissue.

    This new skin tissue is, in turn, more even in tone and texture. It’s normal for the skin to lose collagen via age or injury. By encouraging the skin to make new tissue, there may be more collagen to help make the skin firmer, too.

     

    Procedure

    During the procedure, your practitioner makes small pricks under the skin with a pen-like tool. The pinpricks are so small that you likely won’t notice them after the procedure. Your practitioner will move the tool evenly across your skin so that the new skin that rejuvenates will be even, too.

    Before getting started, your practitioner will use a topical anesthetic to reduce the chances of pain. This is done about an hour before your treatment. The actual microneedling process takes approximately 30 minutes.

    Your practitioner will then apply a serum or calming treatment.

     

    Potential Risks and Side Effects

    • Although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In case of any complications (signs of infection, scarring or pigment changes) Immediately contact a medical professional.
    • Some degree of discomfort like burning, stinging sensation, hotness or tightness during and just after the treatment.
    • You may or may not have visible redness and that each case is individual.
    •  Side effects or risks are minimal with this type of treatment and typically include minor flaking or dryness of the skin with scab formation in rare cases.
    •  Hyper-pigmentation (darkening of certain areas of the skin) can occur very rarely and usually resolves after a month.
    •  If you have a history of cold sores, this procedure may cause flare ups.
    •  Temporary redness and mild-sunburn effects may last up to 4 days.
    •  Freckles may temporarily lighten or permanently disappear in treated areas.
    •  Other potential risks include: crusting, itching, discomfort, bruising, infection,
      swelling, and failure to achieve the desired result. Permanent scarring (less than 1%) is extremely rare.

  • AFTERCARE

  • MICRONEEDLING AFTERCARE INSTRUCTIONS
    To ensure optimal results and minimize the risk of irritation or complications, please carefully follow the aftercare instructions below:

    Immediately After Treatment (First 24 Hours)

    • Redness & Sensitivity: Your skin may appear red, feel warm, and be slightly swollen—similar to a mild sunburn. This is normal and should subside within 24-48 hours.
    • Avoid Touching: Keep your hands away from your face to prevent irritation or infection.
    • No Makeup: Refrain from applying makeup for at least 24 hours to allow your skin to heal.
    • Use Gentle Skincare: Only use a mild, non-active cleanser and a hydrating, non-comedogenic moisturizer as recommended by your technician.
    • Stay Hydrated: Drink plenty of water to aid the healing process.
    • Avoid Sweating: No intense workouts, saunas, or hot showers for at least 24 hours, as heat and sweat can cause irritation.

    Days 2-7: Healing Phase

    • Mild Peeling & Dryness: Some flaking or dryness may occur. Do not pick or exfoliate the skin—let it shed naturally.
    • Keep Skin Moisturized: Continue using a gentle, hydrating moisturizer to support healing.
    • Use Sunscreen: Your skin is more sensitive to the sun. Apply a broad-spectrum SPF 30+ daily and avoid direct sun exposure for at least a week.
    • Avoid Harsh Skincare Products: Skip retinols, acids (AHAs/BHAs), vitamin C, and exfoliating scrubs for at least 7 days.

    Long-Term Care (1-4 Weeks Post-Treatment)

    • Continue Sun Protection: Prolonged sun exposure can affect results and cause hyperpigmentation. Always wear SPF!
    • Resume Regular Skincare Gradually: You can slowly reintroduce active ingredients (retinol, exfoliants) after one week, as advised by your technician.
    • Optimal Results: Best results appear after multiple sessions. Follow your treatment plan for long-lasting improvements in skin texture, tone, and collagen production.

    There are no guarantees as to the results of this treatment, due to many variables, such as: age, condition of skin, sun damage, smoking, climate, life style and etc.

  • ACKNOWLEDGMENT

  • Please read each statement carefully. By checking each box, you confirm that you understand and agree to the statement.

  • I,         am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and voluntarily consent to receive the microneedling procedure. I understand the nature, risks, and possible complications of the treatment and acknowledge that I am proceeding of my own free will without being pressured or rushed.

  • Date*
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