BOOK NOW
0456 296 373

Skin Needling and Skin Microdermabrasion Form

    Skin Needling & Skin Microdermabrasion Form

    Medical History and Contraindications:

    Please indicate if you have any of the following conditions:

    Pregnancy or BreastfeedingCardiovascular conditions (e.g., heart conditions, hypertension)DiabetesRecent surgerySkin infections or active acneBotox or fillers (within the last week)Any condition currently being treated by a doctorAny metal pins or plates in the bodyAllergies to products or medicationsNervous system disorders (e.g., epilepsy, Bell's palsy)

    Skin Assessment:

    Please describe the condition of your skin (check all that apply):

    DryOilyCombinationSensitiveAcne-proneHyperpigmentationFine lines/wrinklesUneven texture

    Treatment Goals:

    What are your primary goals for this treatment?

    Pre-Treatment Questions:

    Please answer all following questions:


    YesNo


    YesNo


    YesNo


    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: