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Microneedling Intake & Consent Forms
Details

Microneedling, also known as Collagen Induction Therapy, is a skin rejuvenation technique utilizing a sterile device equipped with fine needles. Slender needles gently penetrate beneath the skin’s surface, creating micro-wounds and micro-injuries. These microscopic wounds trigger the body’s innate defense mechanisms, prompting the production of new skin cells, capillaries, and collagen for the purpose of repairing the damage. The natural restorative process results in a more youthful appearance due to the increased collagen synthesis.

Benefits

  • Stimulates Collagen & Elastin

  • Reduces Fines Lines & Wrinkles

  • Smoothes Texture

  • Minimizes Pore Appearance

  • Treats Acne Scars

  • Evens Skin Tone & Reduces Hyperpigmentation

Pre-Treatment

  • Avoid retinols, exfoliants, topical antibiotics, or acids 3-5 days prior to treatment.

  • Avoid waxing the treatment area within 7 days of treatment.

  • Refrain from blood thinning agents 7 days prior to treatment.

  • Avoid anti-inflammatory medications like Ibuprofen, Motrin, or Advil 3 days prior to treatment.

  • For individuals prone to cold sores, consider taking an antiviral agent for 2 days prior and on the day of treatment.

  • Do not shave the day of treatment to avoid skin irritation. If there's dense hair present in the treatment area, shave the day before appointment.

Post-Treatment

  • It’s normal for the skin to feel sunburnt, tight, dry, or swollen for 1–3 days post-treatment. These effects are temporary and part of the healing process.

  • Avoid touching the treated area within 6 hours following treatment

  • Do not rub or massage the treated area

  • Avoid makeup products for 24 hours

  • Avoid sun exposure, tanning beds, saunas and hot tubs for 24 hours

  • Postpone workout sessions to the following day

Possible Side-Effects

  • Side effects or risks are minimal with this treatment and typically include minor flaking or dryness of the skin.

  • If you have a history of cold sores, this treatment may cause flare ups.

  • Temporary redness and mild-sunburn effects may last up to 4 days.

Microneedling Intake Form

Date Of Birth
Month
Day
Year
Do You Suffer From Any Blood Disorder? (Thrombosis, Hemophilia, Anemia)
Yes
No
Do You Have Diabetes? (Type 1 Or 2)
Yes
No
Do You Have Any Type Of Hepatitis? (A, B, C, D, E, F)
Yes
No
Are You Allergic To Metals?
Yes
No
Do You have Any Autoimmune Disorder?
Yes
No
Do You Suffer From Any Acute Or Chronic Infectious Disease?
Yes
No
Are You Prone To Cold Sores?
Yes
No
Do You Have Epilepsy Or Any Other Seizure-Related Condition?
Yes
No
Do You Have Any Heart-Related Problems?
Yes
No
Are You Pregnant Or Nursing?
Yes
No
Do You Have Any Problems Healing From Wounds?
Yes
No
Do You Scar Easily From Minor Skin Injuries?
Yes
No
Do You Bleed Excessively From Minor Cuts?
Yes
No
Are You Allergic To Numbing Cream Or Lidocaine?
Yes
No
Are You Currently Using Any Products That Contain The Following Ingredients?
Contraindications
How Would You Describe Your Skin Type?

Microneedling Consent Form

Date
Month
Day
Year

akayskin llc

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