Microneedling Consent

Microneedling Consent

Time to get spoiled !
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Treatment area(s)
Medical History / Contraindications

(Yes–No Questions)

1.Are you pregnant or breastfeeding?

2.Do you have active acne, infections, open wounds, or cold sores in the treatment area?

3.Do you have a history of keloid scarring?

4.Are you on Accutane (in last 6 months)?

5.Have you used Retin-A, exfoliants, acids, or benzoyl peroxide in the last 5–7 days?

6.Are you taking blood thinners?

7.Do you have any chronic skin conditions (eczema, psoriasis, dermatitis)?

If YES to anything above, explain:
Type a question
Treatment Risks

Microneedling may cause temporary redness, swelling, tightness, pinpoint bleeding, sensitivityt, dry/flaky skin, or bruising. Rare risks include infection or pigment changes. Results vary and multiple treatments may be required.
Pre-Treatment Requirements

I have avoided sun exposure/tanning for 1 weekI have stopped retinol/exfoliants for 5–7 daysI have no makeup or skincare products on the area todayI will notify my technician of any medication changes
Photo consent

I consent to before/after photosI do NOT consentI agree to photo use for marketing (identity hidden)I do NOT consent to marketing use
Date

MonthDayYear
Date
Signature
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Treatment Risks