Microneedling Consent Form

Patient Information

Full Name

Date of Birth

Phone Number

Email Address

Treatment Type (tick all that apply)

Standard Microneedling - Manual or electric pen device

RF Microneedling - With radiofrequency energy (e.g., Morpheus8, Potenza)

With Topical Serum/Growth Factors - Specify: _________________

With PRP - Platelet-Rich Plasma (separate consent required)

Treatment Area(s)

Needle Depth (mm)

Device Used

Cartridge Batch Number

Contraindications - Please confirm you do NOT have any of the following:

Pregnancy or breastfeeding

Active acne, eczema, psoriasis, or rosacea in treatment area

Active skin infections, cold sores, or open wounds

History of keloid or hypertrophic scarring

Use of isotretinoin (Roaccutane) within the last 6 months

Blood clotting disorders or anticoagulant medication

Active cancer or undergoing chemotherapy/radiotherapy

Diabetes (poorly controlled)

Immunosuppressive conditions or medications

Pacemaker or metal implants (for RF microneedling only)

Sunburn or recent sun exposure in treatment area

Risks and Potential Complications

I understand that the following may occur:

Expected: Redness (like mild sunburn) lasting 24-72 hours

Expected: Mild swelling, especially around eyes

Common: Skin tightness and dryness for several days

Common: Pinpoint bleeding during treatment

Uncommon: Bruising

Uncommon: Post-inflammatory hyperpigmentation (higher risk in darker skin)

Rare: Infection

Rare: Scarring

Rare: Reactivation of cold sores (herpes simplex)

Rare: Allergic reaction to topical products used

Patient Acknowledgements

I have read and understood this consent form and agree to proceed with treatment.

Patient Signature

Date

Practitioner Signature