Microneedling for Hair Growth Intake Form

Microneedling for Hair Growth Intake Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Emergency Contact*

NamePhone Number
Medical History
Please check all that apply:*

Scalp infections, psoriasis, eczema, or dermatitisOpen wounds, cuts, or sores on the scalpRecent scalp surgery or hair transplant (last 6 months)History of keloid scarring or abnormal wound healingActive acne or folliculitis on scalpBlood clotting disorders or anticoagulant therapyDiabetes (Type I or II)Autoimmune disease or immunosuppressive therapyUse of Accutane in past 6 monthsSkin cancer on scalpPregnant or breastfeedingNone of the above
Treatment Information

Microneedling for hair growth uses a device with fine needles to create controlled micro-injuries in the scalp. This stimulates blood flow, promotes natural growth factors, and may increase absorption of topical serums. Results vary depending on individual health, genetics, and consistency of treatments.
Possible Risks & Side Effects

I understand that possible risks include:
- Temporary redness, soreness, swelling, or sensitivity of scalp
- Pinpoint bleeding or bruising
- Scalp dryness, flaking, or mild scabbing
- Itching or tightness in treated area
- Temporary hair shedding before regrowth (shedding phase)
- Infection if post-care is not followed
- Rare: scarring or pigment changes
Contraindications

I understand I should not undergo scalp microneedling if I have:
- Active scalp infection, fungal infection, or severe dandruff
- Open wounds, sores, or lesions on scalp
- Uncontrolled diabetes or healing disorders
- History of keloids or hypertrophic scars
- Blood clotting disorders or use of blood thinners
- Recent radiation or chemotherapy
- Current use of Accutane (within 6 months)
Pre-Treatment Guidelines
I agree to:*

Wash hair and scalp before appointment (arrive with clean scalp, no styling products).Avoid hair dye/bleach for at least 72 hours before treatment.Discontinue retinoids, acids, or harsh scalp treatments 5 days prior.Avoid sunburn or excessive sun exposure on scalp prior to session.
Post-Treatment Guidelines

I understand that after treatment I should:
- Avoid washing hair or using shampoo/conditioner for 24 hours.
- Avoid hair dye, bleach, or chemical treatments for 7 days.
- Avoid sweating, swimming, saunas, and hats/helmets for 48 hours.
- Avoid touching, scratching, or picking the scalp.
- Use only recommended hydrating serums or products provided.
- Apply sunscreen to scalp (if exposed) after 24 hours.
Photo Consent
Do you consent to before/after photos?*

YesNo
Acknowledgement and Consent
I confirm that:*

I have disclosed all medical conditions, medications, and allergies.I understand microneedling is a cosmetic procedure with no guaranteed results.I understand risks, side effects, and aftercare instructions.I consent to this procedure and release my provider from liability for complications if I fail to follow instructions.I release my provider from liability for any adverse reactions.
Client Name*
Client Signature (If under 18 signature of parent or guardian)*
Date*

MonthDayYear
Should be Empty:

Microneedling for Hair Growth Intake Form

Medical History

Treatment Information

Possible Risks & Side Effects

Contraindications

Pre-Treatment Guidelines

Post-Treatment Guidelines

Photo Consent

Acknowledgement and Consent