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Microneedling intake & consent

Comprehensive form for microneedling treatments with skin analysis, medical history, contraindications and professional patient consent.

Treatment requests & skin analysis1/5

Treatment requests & skin analysis

Which skin problems would you like to treat with microneedling? *

Acne scarsFine lines and wrinklesEnlarged poresUneven skin tonePigment spots/hyperpigmentationStretch marksGeneral skin improvementScars (other than acne)Pale, tired skinOther

If 'Other' is selected, please specify:

Which skin type best suits yours? *

Type I (very fair, always sunburned, never tans)Type II (light, burns quickly, tans minimally)Type III (moderate, sometimes sunburns, tans well)Type IV (darker, rarely sunburns, tans quickly)Type V (dark, very rarely sunburn)Type VI (very dark/black, never sunburned)

How would you describe your current skin condition? *

Normal and healthyDry and flakyGreasy with shineCombination skin (T-zone oily, cheeks dry)Sensitive and reactiveUnclean with pimples/blackheadsMature skin with wrinkles

Which of the following skin problems do you currently have? *

Active acne/pimplesRosacea/couperoseEczema/dermatitisOpen woundsHerpes/cold soresSunburnSevere rednessNone of the mentioned

Do you already have experience with microneedling? *

Yes, professionallyYes, at homeNo, for the first time

If yes, describe your experience:

What expectations do you have of the treatment? *

Significant improvement in skin structureModerate improvement over multiple sessionsPreventive anti-aging measureSpecific scar treatmentUnsure, please advise