Microneedling Client Information Form
Today's Date
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Month
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Day
Year
Date
Name
First Name
Last Name
Your Date of Birth
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Month
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Day
Year
Date
Phone Number
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Area Code
Phone Number
Email
example@example.com
List any and all allergies
List any prescribed medications you are currently taking:
Have you ever had a Microneedling treatment done before?
Yes
No
If yes, when did you have them done?
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Month
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Day
Year
Date
If yes, how was your healing?
Do you have a forehead lift?
Yes
No
If yes, when?
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Month
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Day
Year
Date
Have you had Botox or Fillers anywhere within the face or neck?
Yes
No
If yes, when?
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Month
-
Day
Year
Date
If yes, exact location of the injections, for example in between brows, forehead, crows feet, lips, cheeks...etc
How would you describe your skin type?
Oily
Dry
Normal
Combination
Sensitive
What are your wanting to work on during this Microneedling treatment/series?
Acne Scars causing depressions and/ or texture
Acne Scars pigmentation
Fine Lines and Wrinkles
Large Pores
Do you extreme keloid tendency?
Yes
No
Have you ever had fever blister or cold sore?
Yes
No
If yes, how do you treat them when you have an outbreak?
Do you tan in a tanning bed?
Yes
No
Do you exercise?
Moderately
Not really
3-4 times a week
As much as you can
Have you had Chemo or Radiation within the last 6 months?
Chemo
Radiation
No
Medical History
Have you ever had MRSA?
Yes
No
If yes, when?
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Month
-
Day
Year
Date
Do you have diabetes?
Yes
No
If yes, explain:
Do you have Hepatitis A, B, C, D, E
A
B
C
D
E
No
Have you been diagnosed with any blood thinning disorder?
Are you currently doing any anticoagulant therapy?
Do you have alopecia or trichotillomania (complusive pulling of hair)?
Yes
No
Alopecia
Trichotillomania
Have you had any facial surgeries? If yes, list all surgeries below with dates.
Any history of alcoholism?
Yes
No
Do you have an abnormal heart condition? If yes, explain:
Are you currently pregnant or breastfeeding?
No
Pregnant
Breastfeeding
Do you have an auto immune disease? If yes, explain:
Have you ever been diagnosed with cancer? If yes, explain and are you in remission?
If yes, when?
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Month
-
Day
Year
Date
Have you been diagnosed by a Dermatologist with any chronic skin diseases such as: Rosacea, Eczema, Psoriasis, Dermatitis, Vitiligo, Lichen Planus, etc.
Do you have tumors, growths, or cysts within the face?
Yes
No
If yes, explain:
Are you currently taking any blood thinners?
No
Aspirin
Ibuprofen
Alcohol Daily
Coumadin
Fish Oil
Xarelto
Eliquis
Heparin
No
Are you currently taking Accutane?
Yes
No
Have you had a chemical peel within the past 30 days?
Yes
No
If yes, when did you receive your last peel?
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Month
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Day
Year
Date
Does your skincare routine consist of anything with Retin-A, Retinols, or any other exfoliating acids or buffing agents? Please list all, plus what brand:
Are you currently under the care of an esthetician, plastic surgeon, dermatologist, or any general spa where you receive facial treatments? If yes, please list which one:
Submit
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