Microneedling Consent Form
1. Description of the Procedure
Microneedling is a cosmetic treatment that uses fine needles to create controlled micro-injuries in the skin. This process stimulates collagen and elastin production, which may improve the appearance of fine lines, scars, texture, and overall skin quality.
2. Potential Benefits
Improved skin texture and tone
Reduction in fine lines and wrinkles
Reduced appearance of acne scars and enlarged pores
Enhanced absorption of skincare products
3. Risks and Possible Side Effects
I understand that, as with any cosmetic procedure, risks may include:
Redness, swelling, or sensitivity for several days
Pinpoint bleeding
Bruising
Dryness or flaking
Temporary darkening of pigmentation
Infection (rare)
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Allergic reaction to topical products used during treatment
4. Contraindications
I confirm that I have informed the practitioner if I have:
Active acne, eczema, psoriasis, or open wounds in the treatment area
Active cold sores
Recent sunburn
Use of Accutane/Isotretinoin within the last 6–12 months
Pregnancy or breastfeeding (unless cleared by a medical professional)
History of keloid scarring
Blood clotting disorders or use of blood-thinning medication
Recent chemical peel, laser treatment, or injectables (within recommended timeframes)
5. Pre-Treatment Acknowledgement
I agree to:
Avoid sun exposure, tanning beds, and self-tanners for at least 48 hours before treatment
Avoid retinoids, acids, exfoliants, and harsh skincare for 3–5 days before treatment
Arrive with clean skin free of makeup
Post-Treatment Acknowledgement
I understand that after treatment I must:
Avoid touching the treated area with unclean hands
Avoid makeup for 24 hours
Avoid sun exposure, heat, saunas, and strenuous exercise for 48 hours
Use only recommended gentle skincare products
Apply SPF daily
6. Results & Expectations
I understand that:
Results vary from person to person
Multiple sessions may be required for best results
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Full results may take several weeks to appear
No guarantees have been made regarding the outcome
7. Photography Consent (Optional)
I consent/do not consent to before-and-after photos being taken.
I consent / do not consent to photos being used for marketing purposes.
8. Client Declaration
I confirm that:
I have disclosed all relevant medical information
I have had the opportunity to ask questions
I understand the risks, benefits, and aftercare
I voluntarily consent to receive microneedling treatment
Client Signature:
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Client Name:
First Name
Last Name
Date of Birth:
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Address:
Email Address:
example@example.com
Phone:
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Client Signature:
Date:
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