Name *

First Name

Last Name

Although majority of patients do not experience any complications, it is still important to understand that this is a minimally invasive procedure, and it is important to understand pre and post care to get the best results. Do you understand? Please select Y or N

Yes

No

Do you currently have any active viral or bacterial infections?

Yes

No

Do you have any rashes or warts?

Yes

No

Are you currently using Accutane?

Yes

No

Are you currently under the care of a dermatologist?

Yes

No

Do you have skin related auto immune disorders?

Yes

No

Do you currently take anticoagulants? (Blood Thinners)

Yes

No

Are you pregnant?

Yes

No

Have you received any recent dermal procedures?

Yes

No

Do you currently suffer from eating or psychological disorders?

Yes

No

Are you HIV positive? Microneedling cannot be performed on individuals with HIV because of the infection risks

Yes

No

Do you have keloids?

Yes

No

Do you have Diabetes?

Yes

No

Have you answered each question truthfully and to the best of your knowledge?

Yes

No

By completing this form, you are acknowledging that you understand everything that you have read and you are consenting.

Yes

No