• Client Health History: MicroNeedling Intake

    Please complete this client health history form for microneedling. Preserve the wording and order of the requested fields as closely as possible.

  • Client Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Contact*
  • Format: (000) 000-0000.

  • Skin Type & Skincare Products

  • Skin Type (Fitzpatrick Scale)*
  • Are you of Asian heritage (Class V) and/or have a history of keloid scarring?*

  • Cosmetic History

  • Have you had needling or collagen induction therapy in the past?*
  • Are you prone to keloid or hypertrophic scarring?*
  • Injectables/Implants Received
  • Have you had any recent cosmetic surgeries/procedures?*
  • Have you used Accutane in the past year?*
  • Do you have hyperpigmentation or hypopigmentation or marks after physical trauma?*
  • Do you have any tattoos in the area to be treated?*

  • Health History / Medical Conditions

  • Health Conditions
  • Do you have any other health condition not mentioned here?*
  • Do you have moles or skin growths in the area to be treated?*
  • Have you ever had a reaction at the dentist or any other time from numbing?*

  • Allergies, Medications, Supplements, Substance Use

  • Do you have any allergies to medications, food, latex, topical products, or other substances?*
  • Have you consumed drugs or alcohol in the last 24 hours?*

  • Additional Info & Signatures

  • Client Signature Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Esthetician/Technician Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: