Skin Needling and Skin Microdermabrasion Form

Skin Needling & Skin Microdermabrasion Form

Treatment Goals:

What are your primary goals for this treatment?

Pre-Treatment Questions:

Please answer all following questions:

Have you had Botox or filler injections within the past two weeks? YesNo

Have you been using any strong acids, such as AHA/BHA? YesNo

Do you currently have sunburn on your face? YesNo

Have you undergone any deep exfoliation treatments or chemical peels within the past two weeks? YesNo

Contraindications for Microneedling:

Please check below if you have any of the following conditions:

Active skin conditions, such as acne, eczema, or psoriasis.A history of keloid scars or hypertrophic scars.Use of anticoagulant medications (e.g., aspirin).Uncontrolled diabetes.Blood disorders.Recent facial surgery or laser treatments (within the past 4-6 weeks).Allergies or sensitivities to topical creams used during the procedure.

Pre-Treatment Instructions:

Before the treatment, please:

Avoid Retinol, exfoliants, and harsh skincare products for 48 hours.
Refrain from sun exposure or tanning for at least one week.
Inform us of any changes in your health or medications.

Description Note:

Write down details about the service performed (e.g., what colors or products were used, any specific issues the customer had, etc.).

Consent:

I confirm that I have provided accurate and truthful information about my medical history and understand the risks and benefits of the treatment. I agree to proceed with the Skin Needling/Microdermabrasion treatment as discussed.

I confirm that all information provided is true and correct.

Signature: