Microneedling Intake Form

Microneedling Intake Form

Hello! This form ensures you are able to have collagen induction therapy (CIT) or microneedling services. It will also list pre-treatment and post-treatment instructions and care. I will ensure you have that information in a more permanent location as well. I look forward to seeing you at your next appointment!
Client Full Name*

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What is your goal for your microneedling/CIT treatments?*
SclerodermaCollagen vascular diseasesCardiac abnormalitiesBlood clotting problemsCurrently active bacterial or fungal infectionImmune-suppression diseasesScars less than 6 months old in area to be treatedFacial fillers in the past 10 daysWarts in or near the area to be treatedAccutane in the last 12 monthsEczemaPhotosensitivitySevere seasonal allergiesLiver diseaseHepatitisRadiation treatment in the last 12 monthsActive skin infection in the area to be treatedCurrent cold sore or herpes simplex outbreakNone of the above
If you would like to expand on any of the above answers:
History of keloids, raised, or hypertrophic scarsHistory of eczema or psoriasisHistory of chronic skin conditionsUncontrolled diabetesControlled diabetesRaised moles, warts, lesions in the area to be treatedUse of blood thinners in 3-5 days before appointmentPregnancyHistory of poor wound healingNone of the above
If you would like to expand on any of the above answers:
I understand: This technique involves the introduction of fine needles, steel cones, and/or silicone cones to and/or through the skin. The purpose is to create micro-channels in the skin, allowing the infusion of active ingredients (such as growth factors & hyaluronic acid) to penetrate deeply and effectively into the dermis, nourishing the skin and stimulating the regrowth of collagen. A series of 4 to 6 treatments is recommended, and the frequency will depend on the intensity and depth of the needle as well as my personal needs.

I understand that the treatments require many small, shallow injections in the area(s) to be treated. I understand that the administration of numbing creams may be used if deemed necessary for my comfort.
I understand the above
I understand that there are some risks with any procedure. The following are possible reactions with Microneedling and CIT: temporary bruising, skin discomfort during the procedure, redness, swelling, lightening or darkening of the skin, itching, burning sensation, dryness, flaking, track marks, breakouts, histamine reaction, cold sores, granulomas (result of foreign substances, makeup, or sunscreen). Skin infection is a possibility any time an injection-type procedure is done. Side effects are most of the time mild and temporary, typically resolving within 3 days. Total healing time depends on the depth of the treatment, skin type, and skin condition. Some patients may heal completely in 24 hours.
I understand the above
Your esthetician will take photos of the area to be treated before and after the procedure. This will be kept in your confidential file to track your progress in the treatment plan. Photos can, with your consent, be used for educational or promotional purposes as well.
Do you consent to your photos being used for educational and/or promotional purposes:*
By my signature, I certify that I have thoroughly read and understand the contents of this form, and the disclosures listed above were made to me. I acknowledge that no promises or guarantees have been made to me as a result of the treatment.

I am aware that the results achieved by this treatment may vary from person to person. Some patients notice an immediate glow, but visible improvement will take about 2-4 weeks after each session and can continue for up to 6 months.

I have read potential risks. They have been explained to me, and I accept them.

I hereby give my voluntary consent to have this treatment performed on me.
Please confirm the above by signing below:*
Pre-Treatment Instructions & Recommendations
1. Use agreed upon gentle cleanser and other products.
2. Avoid direct sun exposure or tanning bed at least 4 weeks prior to treatment and during treatment plan process.
3. Do not exercise the day of or for 48 hours after the treatment.
4. Avoid caffeine-containing food or beverages day of treatment.
5. Avoid medications such as: Aleve, Advil, Ibuprofen, Motrin, cold remedies, Vitamin E, or aspirin 5 days prior to treatment.
6. Avoid Retin-A, chemical peels, injectable fillers, or Botox for 2 weeks prior to treatment.
7. Discontinue Hydroquinone, Reinoids, AHA’s, BHA’s, Benzoyl peroxide, and any other possible irritants 3-5 days prior to treatment.
8. Use a sunblock with an SPF 30+ with UVA/UVB Broad Spectrum protection daily.
9. Apply topical anesthetic cream 30 minutes - 1 hour prior to procedure and reapply if necessary. *Your esthetician may do this for you.*
10. Day of treatment, I recommend a top that buttons or zips rather than pulls over the head.
11. Notify medical professional or esthetician if you are prone to cold sores. You will require supplement such as Lysine or an antiviral prescription to help avoid any breakout after treatments.
12. If you have open cuts, wounds, abrasions, active acne, or cold sores breakouts, we cannot do the procedure in those areas.
13. Eat a healthy diet like whole foods, vitamins, and minerals. It is also advisable to take Vitamin C daily. This ensures an increase in vitamins internally and externally as well as greatly aiding in the healing process. Hyaluronic acid is recommended to retain moisture in the skin and prevent dehydration.
14. Drink 8 glasses of water per day.
I agree to abide by them.
Post-Treatment instructions

These will be explained during your appointment and emailed to you after your appointment.
1. Gently wash the treated area with the provided gentle cream cleanser and your fingers only. Gently massage the face with tepid water to remove serum and other debris, such as dried blood. Do NOT scrub or use a washcloth, Clarisonic-type brush, or the cleanse-mode setting with heat on the My Skin Buddy. Cleanse treated area twice a day. Do not use exfoliating products for 72 hours.
2. Keep skin hydrated with the provided post-care products. It is very important to keep the skin hydrated in the days following your treatment. New cell regeneration requires at least 6-8 8oz glasses of water per day (if you already drink that much, consider increasing by 2 glasses temporarily)
3. Cool compresses may be applied following treatment for comfort. If neck or décolletage are treated, the redness might last slightly longer.
4. Do not exercise for 24 hours after treatment, and avoid strenuous exercise for 2-3 days after treatment, until redness completely subsides.
5. Avoid saunas, steam rooms, and hot baths or showers until redness is gone.
6. Continue to avoid direct sun exposure to the treatment areas. Beginning 1-2 days after treatment, apply a broad spectrum sunblock with SPF 30+. Apply at least 30 minutes prior to sun exposure and repeat after every two hours of sun exposure.
7. After 2-5 days (or whenever the redness in the skin dissipates or as soon as it is comfortable to do so), you may return to your regular recommended skincare products. Mineral makeup may be applied the day following treatment.
8. Avoid waxing, facials, Botox, injectable fillers, or any other skin care treatment for 10 days after treatment.
9. If skin becomes painful, swollen, increasingly red or inflamed, please notify your skin care professional, as this may represent an infection or allergic reaction that may require treatment.
I agree to abide by them.
Please sign below to indicate your agreement to the above statement.
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Microneedling Intake Form

Pre-Treatment Instructions & Recommendations

Post-Treatment instructions