Microneedling Intake Form
Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Age
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Treatment Information
Microneedling is a minimally invasive skin rejuvenation treatment that uses fine needles to create controlled micro-injuries in the skin, stimulating collagen and elastin production to improve texture, reduce fine lines, minimize scars and pores, and enhance overall radiance with little downtime.
Contraindications
Please check all that apply:
*
Pregnant or breastfeeding
Active skin infection, cold sores, or open wounds
Accutane use within the last 6 months
Uncontrolled diabetes
Blood clotting disorders or anticoagulant use
History of keloids or abnormal wound healing
Active eczema, psoriasis, or dermatitis
Recent sunburn or tanning
Skin cancer in the treatment area
None of the above
Possible Risks & Side Effects
I acknowledge that I have been informed of the possible side effects:
*
Redness, swelling, or sensitivity (24–72 hours)
Dryness, flaking, or minor peeling
Temporary pinpoint bleeding or bruising
Itching or tightness of skin
Infection, scarring, pigment changes, or cold sore reactivation
Pre-Treatment Guidelines
I understand and agree with the following conditions:
*
I will avoid retinoids, acids, and exfoliants for 5 days before treatment
I will avoid tanning/sun exposure for 1 week before
I will consult my doctor before stopping blood-thinning meds
I will arrive with clean skin
Post-Treatment Guidelines
I understand and agree with the following conditions:
*
I will avoid sun, swimming, saunas, and sweating for 48–72 hours
I will use only gentle skincare as directed
I will apply sunscreen daily
I will avoid makeup for 24 hours
I will not pick, scratch, or touch treated skin
Photo Consent
Do you consent to before/after photos?
*
Yes
No
Acknowledgment & Consent
I confirm that:
*
I have disclosed all relevant medical info.
I understand results vary and multiple treatments may be required.
I understand this is a cosmetic, not medical, procedure.
I release my provider from liability if I fail to follow instructions.
Client Signature (If under 18 signature of parent or guardian)
Date
 -
Month
 -
Day
Year
Submit
Submit
Should be Empty: