Microneedling Consultation and Consent Form

Client Details

Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently, or possibly may be, pregnant? *

Do any of the following apply to you? Please tick all that apply.

Do you have any other medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

In the last 4 weeks have you had any dermal treatments such as tattoos, dermal fillers, piercings or botulinum toxin? *

Please specify treatment type and date: *

Fitzpatrick skin types:

1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

Which of the above skin types would you say is closest to your skin? *

What are your main skin concerns? *

What are your goals and expectations of the treatment? *

Treatment Information

What is Microneedling?

Microneedling is a minimally invasive cosmetic procedure that’s used to treat skin concerns via collagen production. Also known as collagen induction therapy, this treatment may help those looking to reduce the appearance of acne scars and stretch marks.

It’s also used in certain anti-aging procedures, such as eyelid surgery and sun spots. Microneedling isn’t effective for hair loss, despite the possible role of collagen in hair growth.

Microneedling works by encouraging your skin to make more collagen. The idea is that pinpricks from the procedure cause slight injury to the skin and that the skin responds by making new collagen-rich tissue.

This new skin tissue is, in turn, more even in tone and texture. It’s normal for the skin to lose collagen via age or injury. By encouraging the skin to make new tissue, there may be more collagen to help make the skin firmer, too.

Procedure

During the procedure, your practitioner makes small pricks under the skin with a pen-like tool. The pinpricks are so small that you likely won’t notice them after the procedure. Your practitioner will move the tool evenly across your skin so that the new skin that rejuvenates will be even, too.

Before getting started, your practitioner will use a topical anesthetic to reduce the chances of pain. This is done about an hour before your treatment. The actual microneedling process takes approximately 30 minutes.

Your practitioner will then apply a serum or calming treatment.

Potential Risks and Side Effects

Like all cosmetic procedures, microneedling isn’t without risk. The most common side effect is minor skin irritation immediately following the procedure. You may also see redness for a few days. Seek medical advice if you notice more severe side effects, such as:

Bleeding
Bruising
Infection
Peeling

Aftercare

Microneedling is a non-invasive treatment, so the recovery time is minimal. Most people require very little downtime, if any at all.

You may notice skin irritation and redness within the first few days following the procedure. This is a natural response to the small pricks made by the needles in your skin.

You can go back to work or school after the procedure if you’re comfortable.

Your skin will be more sensitive to the sun, so be sure to apply sunscreen. Wait one week before exposing your skin to sunlight and harsh chemicals.

After microneedling, your skin works fairly quickly to rejuvenate new tissue. In theory, you should see results within a couple of weeks.

To maintain the results of your treatment, you’ll need multiple sessions and perhaps other complementing treatments. Your practitioner can advise you on the best plan of action based on your individual goals.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive a Microneedling treatment.

Client Signature: *

Tap or click on the signature above to sign