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Micro Needling Consultation & Consent Form

Microneedling Consent Form

Microneedling is a minimally invasive cosmetic treatment that uses fine sterile needles to create controlled micro-injuries in the skin. This process is designed to stimulate the skin's natural healing response and collagen production, helping improve the appearance of skin texture, fine lines, acne scars, enlarged pores, and overall skin quality.

Microneedling may cause temporary redness, swelling, sensitivity, tenderness, dryness, peeling, pinpoint bleeding, or bruising. Results vary from person to person and a course of treatments may be recommended depending on your individual skin concerns and treatment goals.

Title Mr.Mrs.MissMs. Full Name Date Street Address Phone Email Address Date of Birth Emergency Contact Please list all medications you take regularly Allergies Are you currently under doctor's care? YesNo Are you currently pregnant or breastfeeding? YesNo Do you have an active skin infection, cold sore, rash, open wound, or inflammation in the treatment area? YesNo Do you have a history of keloid or excessive scarring? YesNo Do you have a bleeding or blood-clotting disorder? YesNo Are you currently taking blood-thinning medication or medication that affects blood clotting? YesNo Are you currently taking or have you recently taken Roaccutane / Isotretinoin? YesNo Do you have diabetes or any condition that may affect wound healing? YesNo Do you have an autoimmune disorder or a condition that affects your immune system? YesNo Do you have eczema, psoriasis, rosacea, active acne, or another skin condition in the treatment area? YesNo Have you recently had laser treatment, chemical peel, dermabrasion, surgery, Botox, dermal fillers, or another cosmetic procedure in the treatment area? YesNo If Yes, please provide details Do you have any known allergies or sensitivities to topical anaesthetics, antiseptics, skincare products, or other products that may be used during treatment? YesNo Are you currently using prescription or active skincare products such as Retinol, Retinoids, AHA/BHA acids, Benzoyl Peroxide, or other exfoliating products? YesNo If Yes, please provide details Do you have any permanent makeup, implants, fillers, or other cosmetic materials in the treatment area? YesNo If Yes, please provide details Have you had recent unprotected sun exposure, sunburn, or tanning (natural or artificial) on the treatment area? YesNo If Yes, please provide details Do you smoke? YesNo How did you hear about us? What skincare regime do you currently have? How many glasses of water do you consume daily? When was the last time you had unprotected sun exposure on the treatment area?

Medical History

Please tick any conditions that apply:

Heart rhythm disturbanceHaemophiliaThyroid disordersCancerHepatitisDiabetesPacemaker / DefibrillatorHormonal disordersRecent surgeryMetal plates / pinsSurgery within last yearLupusRoaccutane / IsotretinoinHypoglycaemiaPhlebitisEczema or PsoriasisAutoimmune diseaseHIVThrombosisBlood clotting disorderRecent illnessMultiple sclerosisEpilepsyPregnancy

Treatment Information

Treatment Duration
A Microneedling treatment typically takes approximately 45–60 minutes, depending on the treatment area and your individual skin concerns.

Expected Response
Following treatment, the skin may appear red or flushed and may feel warm, tight, sensitive, or tender. Mild swelling, dryness, peeling, pinpoint bleeding, or bruising may occur. These effects are generally temporary.

Potential Risks
I understand that, although microneedling is generally considered a minimally invasive treatment, possible risks include prolonged redness, swelling, irritation, infection, bruising, pigmentation changes, allergic reaction, scarring, or worsening of an existing skin condition.

Aftercare
I understand that I will be provided with aftercare instructions and that following these instructions is important to support healing and reduce the risk of complications. I agree to follow the recommended aftercare instructions.

Consent

I certify that the information I have provided is true, complete and accurate to the best of my knowledge. I confirm that I have had the opportunity to ask questions about the Microneedling treatment and that my questions have been answered to my satisfaction. I understand the purpose, expected benefits, risks, possible side effects and potential complications associated with Microneedling treatment. I understand that alternative treatments may be available and that no specific result or outcome can be guaranteed. I understand the importance of following the recommended post-treatment care instructions and agree to follow them. I voluntarily consent to receive Microneedling treatment at Glemz Hair & Beauty.

Client Declaration

I understand that treatment may be postponed or declined if the practitioner determines that Microneedling is not appropriate or safe for me based on my medical history, skin condition, medications, or other circumstances. Electronic Signature

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Glemz Hair & Beauty Studio - Appointment Booking Request

Glemz Hair & Beauty Studio - Choose your service and preferred time. Our team will review and confirm your booking shortly.

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I understand that submitting this form is an appointment request only. My appointment is confirmed only after Glemz Hair & Beauty Studio confirms the date and time.

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Micro Needling Consultation & Consent Form

Microneedling Consent Form

Medical History

Treatment Information

Consent

Client Declaration

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