Microneedling and Nanoneedling Questionnaire

Client Pre-Appointment Questionnaire

Must be complete prior to scheduling for micro/nano needling.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email*
example@example.com
Occupation:
Which of our services are you interested in?

Microneedling for faceMicroneedling for bodyNanoneedling for faceNanoneedling for bodyRedlight LED for faceRedlight LED for body
How did you hear about me?

Website / OnlineYelpFacebookReferralGrouponOther
If Referral, please list name of who referred you?
If groupon, enter your voucher code here to redeem?
What are your skin care goals?
What are your skin care challenges?

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Identity your facial areas of concern

foreheadbetween eyebrowsright sideleft sideunder eyesnosecheeksjawchinmouthneck
Have you ever had a facial or skin treatment before?*

NoYes
If Yes, where?
If Yes, when?
What Skin Care Products do you currently use?

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizer(s)SunscreenEye Product(s)Lip Product(s)
Do you / have you used:

--- Retin-A currently usingRetin-A within 30 daysRetin-A within 6 monthsRetin-A NoRetin-A Not sure--- Renova currently usingRenova within 30 daysRenova within 6 monthsRenova NoRenova Not sure--- Adapalene currently usingAdapalene within 30 daysAdapalene within 6 monthsAdapalene NoAdapalene Not sure---Accutane currently usingAccutane within 30 daysAccutane within 6 monthsAccutane NoAccutane Not sure--- Differen currently usingDifferen within 30 daysDifferen within 6 monthsDifferen NoDifferen Not sure--- Glycolic Acid currently usingGlycolic Acid within 30 daysGlycolic Acid within 6 monthsGlycolic Acid NoGlycolic Acid Not sure--- Lactic Acid currently usingLactic Acid within 30 daysLactic Acid within 6 monthsLactic Acid NoLactic Acid Not sure--- Mandelic Acid currently usingMandelic Acid within 30 daysMandelic Acid within 6 monthsMandelic Acid NoMandelic Acid Not sure--- Retinol currently usingRetinol within 30 daysRetinol within 6 monthsRetinol NoRetinol Not sure--- Vitamin A derivitives currently usingVitamin A within 30 daysVitamin A within 6 monthsVitamin A NoVitamin A Not sureOther
Have you received any of these hair removal services in the last 30 days?

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
If checked, please note the last time you received hair removal services.
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?

YesNoOther
Have you experienced any of these health conditions in the past or present?

Hormone ImbalanceHormone ReplacementsCancer / Systemic DiseaseCancer drugsHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusAnxietyDepressionHepatitisHeadaches / MigrainesHigh Blood PressureNoneSleep Deprivation/InsomniaHay Fever/AntihistamineAcneEczemaAntifungalsThyroidBirth ControlBody-BuildingChronic Skin ConditionsBlood ThinnersHair RestorationPellagraOther
Do you?

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, Not Applicable
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
Are you a smoker

yesnosocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda,energy drinks)

yesno
Have you ever experienced claustrophobia?

YesNo
Please rate your stress level.

LowMediumHigh
Please let me know if you would like to learn about natural ways to lower stress levels.

YesNo
FEMALE CLIENTS: Are you taking birth control?

YesNoN/A
If yes, please specify
Are you pregnant or trying to become pregnant?

YesNo
Have you recently had a baby and/or are breastfeeding?

YesNo
If Yes, please specify
Any known allergies?

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsNoneOther
Have you used or been prescribed any medications (topical or oral) for acne / acne control?

YesNo
If yes, please specify what medication(s) and date last used.
Any menopause issues?

YesNoN/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

YesNo
MALE CLIENTS What is your current shaving system?

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving?

YesNoN/A
It's very important for you to know the procedures. Please take the time to read through this information. Email me if you feel like you need more information.

Microneedling takes approximately 1 hour and 15 minutes and Nanoneedling takes approximately 1 hour. Our initial session will focus only on the face. Addons for neck or decoltage are allowed in followup sessions.

Microneedling unquestionable contraindications include:

• Scleroderma (hardening of the skin).
• Collagen vascular diseases or cardiac abnormalities.
• Blood clotting problems.
• Active bacterial or fungal infection.
• Immune-suppression diseases.
• Scars less than 6 months old.
• Facial fillers in the past 10 days.
• Warts
• Accutane
• Eczema
• Photosensitivity
• Severe allergies
• Liver disease
• Hepatitis

Microneedling Possible side effects:
- Redness
- Burning/ Stinging
- Dryness
- Flaking
- Track Marks
- Breakouts
- Swelling
- Rash
- Bruising (rare)
- Cold sores (rare)
- PIH (rare)
Please confirm each of the Pre Treatment Instructions for Microneedling and Nanoneedling.

I will come in with clean skin. NO moisturizers, make up or any other products on the skin.NO Sun exposure, tanning beds, self-tanning products for three days prior to procedure. Microneedling can “tattoo” tanning products into the skin. Procedure cannot be done on burned skin.NO chemical peels two weeks prior.NO waxing or chemical depilatories for two weeks prior.NO shaving day of the treatment.Identify any tattoos, including cosmetic tattoos in the treatment area.If you have cold sores, begin treatment with Valtrex prior to treatment and continue for several days.Bring a hat and scarf if it is a sunny day and you have a significant drive home.No Retin-A products or applications 24 hours prior to your treatment.No auto-immune therapies or products 24 hours prior to your treatment.If you are taking a blood thinner, aspirin or any other medication that you have the propensity to bleed easily while on, please tell your practitioner.Avoid aspirin, ibuprofen (Advil, Motrin), Aleve and fish oil for 5 days before each treatment.If you are under a physician’s care and need to discontinue your medication for a few days, always ask your physician prior to each Microneedling appointment.If you are planning to receive Botox, make sure that you give yourself at least 2 weeks post Botox injections before receiving your Microneedling procedure.If an active or extreme acne breakout occurs before treatment, please consult your practitioner. Wait 6 months following oral isotretinoin use.Use a sunblock with an SPF 30+ with UVA/UVB Broad Spectrum protection.If you have open cuts, wounds, abrasions or during acne or cold sores breakouts, we cannot perform the procedure.Dr. Cobb recommends Liquid and topical hyaluronic acid to retain moisture in the skin and prevent dehydration.Dr. Cobb recommends drinking 8 glasses of water/non-caloric fluids per day.If you are pregnant or nursing treatment is not recommended.I will call the office and Dr. Cobb immediately about my health conditions, activities or anything else related to this procedure.Dr. Cobb recommends weekly nanoneedling or monthly microneedling for prevention and to achieve your esthetic goals as it takes the skin up to 30 days to develop new skin cells and replace old ones. Within several days or weeks, you will notice a smoother, more radiantappearance.I confirm that I have read all the Pre treatment Instructions.
Contraindications to Micro needling* Contraindications include allergies to topical lidocaine, inflammatory acne, active herpes labialis or other local infection within the treatment area, keloidal predisposition, and immunosuppression. In addition, care should be taken with concomitant microneedling near botulinum toxin injection sites to avoid potential unwanted toxin diffusion. Topical acne products are typically discontinued for at least three days before treatment; however, with Isotretinoin (formerly known as Accutane) treatments should not be performed for at least six months.

I confirm that I do not have any of the contraindications listed above.I confirm that I do have a contraindications listed above.
To maximize results and prevent complications in order to avoid post-inflammatory hyperpigmentation (PIH) post microneedling / nanoneedling treatment one must recognize the drugs and supplements that cause photosensitivity.
- Antibiotics – Sulpha, Tetracycline, Zithromax, Quinolones
- Antidepressants- Zoloft, Effexor, Elavil, Remeron
- Antihistamines- Benadryl, Claritin, Hismanal, Atarax, Phenergan, Seldane
- Diuretics
- Anti-cholesterol agents
- NSAIDs
- Accutane
- Tretinoin
- Gabapentin & other pain medications
- Benzyl Peroxide
Natural supplements linked to photosensitivity include:
- Arnica
- Vitamin A (Retinol/Retin-A)
- Angelica Seed/Root
- Vitamin B6
- Dong Quai
- Rue
- St. John's Wort
- Dong Quai
Natural supplements and foods which can thin the blood:
- Ginger
- Ginkgo Biloba
- Garlic
- Dong Quai
- Vitamin E
- Turmeric
- Bromelain
- Cayenne Peppers
- Cinnamon
- Grape Seed Extract
- Feverfew
It is imperative to inform Dr. Cobb if you are taking these medications or natural supplements.

NANONEEDLING VS MICRONEEDLING

NANONEEDLING	MICRONEEDLING
Cosmetic	Medical
Creates nano channels to increase effectiveness of serums into the epidermis(top skin layer)	Creates micro injuries through the epidermis and into the dermis (deep skin layers) to stimulate the wound healing response
Stimulates Collagen Production	Stimulates Collagen Production
Reduces the appearance of fine lines	Reduces the appearance of fine lines and deeper wrinkles
Softens superficial acne scars	Treats deeper acne scars, stretch marks, fibrous scars, and hair regrowth
Improves overall skin tone and texture	Improves overall skin tone and texture
Round or square tip, depth of ~.15mm	Needle depth of .25mm to 2.5mm with mutliple needles 11 to 42 depending on desired result.
No numbing cream	Numbing cream required
No downtime	24-48 hours downtime

Additional body areas are not available for first time patients.

NANONEEDLING AND MICRONEEDLING COSMECEUTICAL PRICE LIST AND DESCRIPTIONS
All treatments use a lite Hyaluronic Acid serum as a primer. A 10ml bottle for post treatment home care application is available at an addon cost. Additionally, you may increase your herbal serum % or include active cosmeceuticals to achieve faster results!

Cosmeceuticals are beauty target serums only available with treatment.
I customize and mix actives, tinctures and EO blends the day of your treatment when you preorder and ask me to include a cosmeceutical addon. Please consider the therapeutic benefits you would like to add to your hyaluronic acid primer. A, B3 (Niacinamide), C, E, Acetyl Hexapeptide-8, Collagen Peptide, Coenzyme Q10, Green Tea, Aloe Vera, Boswellia carterii, Glycyrrhiza glabra, Salix Alba and Rose Essential Oil treat your skin for optimal absorption, hydration, improved firmness, elasticity, increased hydration, softness, minimize pore size and blemishes and even reduce age spots and hyperpigmentation when part of a skin care routine. I blend your serum after applying your numbing agent. The process takes 15-20 minutes. The remaining serum is for your post treatment home use.

included - Hyaluronic Acid* - A versatile primer for hydrating and plumping skin. *This is not a peel.

$52 - "Bright Pearl" - Inhibits Hyperpigmentation (Glycyrrhiza glabra)

$52 - "Dewy Juicy Flawless" - Improves skin texture and fine lines (Collagen Peptide)

$48 - "Quenched and Clear" - A gentle exfoliant appropriate for sensitive skin that reduces redness and inflammation (B3)

$48 - "Affirming" - Inhibit photoaging due to the sun, including roughness, fine lines, sallowness, and hyperpigmentation. (A)

$48 - "Shimmering Shield" - Smooths texture and improves the moisture retention of the skin. Supports cell protection and stimulates tissue repair. Protects against premature aging. (E)

$48 - "Sunny Delite" - One of the most powerful antioxidants and collagen stimulators. Improves the look of multiple signs of aging, brightens an uneven skin tone. (C)

$60 - "No-Tox Hero" - Argireline (Acetyl Hexapeptide-8) an anti-wrinkle and skin relaxing agent reduces the appearance of wrinkles brought on by repeated facial expressions, makes skin firm and tight with regular use.

$48 - "Eye Mazing" - Ubiquinol (Coenzyme Q10) preserves the collagen content of the skin.

$48 - "Majestic Treasure" Frankincense (Boswellia carterii) - Improve tone, elasticity, blemishes, and anti aging.

$60 - "Renewable" - Myrrh (Commiphora myrrha)

$68 - "Purity" - Rose (Rosa damascena) - Anti aging, anti-inflammatory, antioxidant, mosturizing.

$48 - "Here Pretty Pretty" - White Willow Bark - salix alba - Increases cellular turnover.

Serum Concentrations:
Lite serum for sensitive skin type as listed
Medium serum for normal skin type add $8.00
Ultra serum is a high concentration for increased layer penetration add $12.00

I have read about the procedures. I have read the information on cosmeceutical addons.

No, I will not include an active.$19.00 - Yes, include the Hyaluronic Acid primer for home care post treatment.Yes, I will include an active. Send an invoice to my email.I would like a Lite Serum$8.00 - I would like a Medium Serum$12.00 - I would like an Ultra Serum$52 - Bright Pearl$52 -Dewy Juicy Flawless$48 - Quenched and Clear$48 - Affirming$48 - Shimmering Shield$48 - Sunny Delite$68 - Cosmopolitan$48 - Botancial Shield$48 - Green Tea$60 - Acetyl Hexapeptide-8$48 - Coenzyme Q10$60 -No-Tox Hero$48 - Eye Mazing$48 - Majestic Treasures$52 - Renewable$60 - Purity$48 - Here Pretty Pretty
Terms of Service / Cancellation Policy*

All sales are final.Appointments are required.I understand that if I arrive more than 15 minutes late for my appointment I may be required to reschedule in order to avoid disrupting the appointments of other patients.All appointment changes require 24 hours advanced notice. No shows / missed appointments shall be charged the full appointment fee. Any vouchers shall be forfeit.I understand that once scheduled, I will not receive further reminders of my appointment.
Please sign the signature field below to indicate that you comprehend, have read and completed this questionnaire truthfully. By submitting you agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. Withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments you are seeking are voluntary and you release the licensed professional from liability and assume full responsibility thereof.

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Client Pre-Appointment Questionnaire

NANONEEDLING VS MICRONEEDLING

NANONEEDLING

MICRONEEDLING

Cosmetic

Medical