Microneedling Treatment Consent

Microneedling, also known as collagen induction therapy, is a minimally invasive procedure that involves using a device with fine needles to create micro-injuries in the skin to stimulate collagen production. The procedure may improve the appearance of fine lines, scars, and skin texture. Please read each section carefully and complete the health information section to help determine if microneedling is appropriate for you.

Please answer the following questions about your health status. All responses are confidential.

Are you currently taking any medications (prescription, over-the-counter, supplements)?

Yes

Please list:

Do you have any allergies (e.g., to topical products, medications, metals)?

Yes

Please specify:

Have you had any recent cosmetic treatments or procedures like chemical peels?

Yes

Please specify:

Have you had any recent cosmetic treatments or procedures like Botox or any other injectables?

Yes

Please specify:

Please read and check each statement to confirm your understanding and agreement.

I understand that microneedling is a cosmetic procedure and that results may vary based on individual skin type, condition, and post-treatment care

I have fully disclosed all my known medical conditions, medications, and any other factors that may affect my suitability for this treatment.

I acknowledge that I may experience temporary redness, swelling, or discomfort after the procedure and that post-care instructions are necessary to follow.

I understand that multiple sessions may be required to achieve desired results and that these will be discussed with me during my consultation.

I am aware I need to wear factor 50 / sunblock on my skin for 24 hours after treatment and no makeup is available to be worn until after the 24hours

I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.

I understand that I must avoid sun exposure for at least 5 days after a micro- needling treatment. I should also wear a daily SPF.

I release [Clinic/Provider Name] and its practitioners from liability associated with this procedure, except in cases of negligence or willful misconduct.

I consent to photographs being taken of the treated area(s) for documentation and improvement tracking. (Photos will remain confidential unless permission is granted for other uses.)

By signing below, I confirm that I have read, understood, and agreed to the terms outlined in this consent form. I am aware of the potential risks, benefits, and side effects of microneedling, and I consent to proceed with the treatment.

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Consent Form Microneedling

Microneedling Treatment Consent

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