Micro-needling Consultation & Consent Form
Introduction to Micro-needling
The concept of micro-needling is based on the skin’s natural ability to repair itself when it suffers
physical damage such as cuts, burns, abrasions or other injuries. Immediately after an injury to the
skin, our body begins the healing process, triggering new collagen synthesis. Micro-needling
intentionally creates very superficial “micro-injuries” to the outermost layer of the skin to induce the
healing process that includes new collagen production. Micro-needling has been shown to reduce the
visibility of acne scars, fine lines, and wrinkles; diminish hyper-pigmentation; and improve skin tone
and texture, resulting in smoother, firmer, younger looking skin.
About the Treatment
The micro-needling procedure is performed in a safe and precise manner with a single-use, sterile
needle head. The treatment session usually takes about 30-60 minutes, depending on the area(s)
being treated. Throughout the procedure, activating agents will be applied to stimulate rejuvenation
process. Then a hydrating facial mask will be applied for hydration. After the procedure, your skin will
be red with mild swelling and/or bruising, and it might feel tight and sensitive to the touch. Although
these symptoms may take 2-3 days to resolve completely, they will diminish significantly within a few
hours after treatment.
Risks of Micro-needling
Although the majority of patients do not experience any complications with micro-needling, it is
important you understand that risks do exist. The micro-needling procedure is minimally invasive and
uses a set of micro-needles to inflict multiple, tiny, punctures/lacerations to the outermost layer of the
skin. Because micro-needling penetrates the skin, it inherently carries health risks, including but not
limited to those listed below. You should discuss any and all health concerns with your therapist
PRIOR to signing this consent form.
INFECTION – Infection is very unusual. However, viral, bacterial, and fungal infections can occur any
time the integrity of the skin is compromised.
PIGMENT/COLOR CHANGE (hyperpigmentation) – Because the dermal penetration associated
with micro-needling is so superficial it doesn’t extend into the layer of the skin containing melanocytes,
hyperpigmentation is very rare. However, failure to follow post-treatment instructions can put you at
risk for hyperpigmentation. You MUST avoid sun exposure for 1 to 2 weeks after a micro-needling
treatment. You should also wear a daily SPF facial moisturizer, which your practitioner can
recommend. Lastly, avoid picking and/or peeling the skin during healing period.
SCARRING – Although normal healing after the procedure is expected, abnormal scars may occur in
both the skin and deeper tissues. In rare cases, thickened or keloid scars may result, especially if you
are prone to keloid scarring anyway. Scars may be unattractive and of different color than surrounding
skin. Additional treatments may be needed to treat scarring.
Micro-needling Consultation & Consent Form
PAIN – There may be a very slight burning, scratchy, and irritated sensation to the skin. This is
usually temporary and is gone within a few hours after treatment. A sudden reappearance of redness
or pain is a sign of infection, and you should notify our office immediately.
PERSISTENT REDNESS, ITCHING, AND/OR SWELLING – Itching, redness, and swelling are
normal parts of the healing process. These symptoms rarely persist longer than 24 hours. However,
treatments received less than 4 weeks apart may induce prolonged symptoms.
ALLERGIC REACTION – Micro-needling is performed with a device whose head contains sterile,
needles, which makes an allergic reaction nearly impossible. However, in conjunction with the
microneedling procedure a variety of products may be used on the face; those products could cause
an allergic reaction. Additionally, since micro-needling increases the penetration of topical
substances, it could cause you to become hypersensitive to products used on the face.
LACK OF PERMANENT RESULT – Micro-needling will not completely or permanently improve skin
texture, tone, elasticity, hyperpigmentation, or scars, or minimize fine lines and wrinkles. It is important
that your expectations be realistic and you understand that the procedure has its limitations.
Additional procedures may be necessary to achieve your desired effect.
UNSATISFACTORY RESULT – Although rare from micro-needling, there is a possibility of a poor
result from any cosmetic procedure. Micro-needling may induce undesirable results, including but not
limited to skin sloughing, scarring, permanent pigment change, and/or other undesirable skin
changes. There is always a possibility that you may be disappointed with the final results of
microneedling.
CONTRAINDICATIONS TO MICRO-NEEDLING
Although it is impossible to list every potential risk and complication, the following are recognized as
known contraindications to micro-needling. Furthermore, it is your responsibility to fully and accurately
disclose all medical history prior to initial treatment, as well as to provide any necessary updates at all
future treatment sessions. If you have any of the conditions listed below, you should bring it to the
attention of your therapist PRIOR to signing this consent form.
CONTRAINDICATIONS TO MICRO-NEEDLING
Active Active infection Blood thinner Cardiac disease Chemotherapy or Vascular
acne medications radiation Disease
Diabetes Eczema, Haemophilia / Hormone Immunosuppression Pregnancy
Psoriasis, bleeding Replacement medication
Dermatitis disorders Therapy
Recent Raised Medication- Photosensitising Keloid/hypertrophic Recent
IPL/Laser lesions(moles, Accutane, medication| scarring chemical
warts, etc.) Aspirin peel
Vascular Rosacea Scleroderma Skin Cancer Telangiectasia Sunburn
lesions
Medical history
Allergies Latex Product Metals=
Medication I have declared all medications I
am currently taking including any Aspirin,
blood thinning medication, Accutane – as
these would be contra-indicated for
treatment.
Do you suffer from cold sores?
Micro-needling Consultation & Consent Form
Medical History- pre-existing conditions,
currently taking any medication, have you
suffered complications following any other
treatment
Anything you feel you should tell me?
Purpose of treatment
Do you have any concerns
Alternative/variant treatments
Discussion of treatment risks as outlined
above
Are you happy to proceed with this
treatment
General Consent and Procedure Permit
Clients Name: Tatiana Gusan
Please read the following statements carefully:
• Application of Skin Needling procedures may be uncomfortable
• A healing period of 4-6 weeks is required before any further procedure can be carried
out
• Further procedures will be required
• There may be swelling or redness following the procedure
• There might be an immediate or delayed allergic reaction to the treatment however, this
is a rare occurrence
• Skin Needling cannot be applied to any person under the age of 18 years
1. I (your name) Tatiana Gusan hereby authorise _____________________ to perform upon myself the
following procedure(s) Micro-Needling
2. I understand that even though I have undergone a patch test, if required, this does not guarantee that I
will not have a reaction to the treatment.
3. I have been advised that all equipment is kept in highest levels of hygiene and that each skin needling
used is new and comes in a sealed pack.
4. I accept and understand that each procedure is a specialised process that requires a course of treatments
to achieve the optimum results, I understand that this is the reason why I will need to return for a further
treatments.
5. I understand that further procedures can be undertaken with a 4-6 week time limit, after the initial
procedure has taken place.
6. I understand that it is my responsibility to book the appointment.
7. The result of the procedure is determined by the following:
• Post procedure care
8. Upon completion of the procedure, there can be some redness and swelling of your skin, which should
subside within 1-4 days. You can continue with normal activities immediately following your procedure,
however, excessive perspiration, exposure to UV rays and applying cosmetics, to the treated area should
Micro-needling Consultation & Consent Form
be avoided. Please see our specific post-procedure directions for more details. You should be assured
that after only one treatment you will feel perfectly comfortable appearing in public.
9. To my knowledge, I do not have any medical, mental or physical disability or impairment that could affect
my wellbeing as a direct or indirect result of my having a procedure carried out. I am not under the
influence of alcohol or drugs. I am over 18 years of age.
10. I agree that I will follow all pre-procedure and post-procedure instructions provided verbally and in writing
as explained to me by my therapist. I confirm that I have received all relevant copies of aftercare
instructions and that I understand that there can be no guarantee or assurance as to the final result that
may be obtained.
11. I have been given the opportunity to ask questions and hereby certify that I have read and fully
understand the contents of this consent form
12. Being of sound body and mind, I accept all and any responsibility that might arise from my decision to
have skin needling treatments.
13. For the purpose of documentation, I am also consenting that I agree to have before and after photographs
taken of my procedure(s) ________________________________ for the use of presentation portfolios.
My signature below acknowledges that I have read and understand the content of this
informed consent document. I have been given ample opportunity to ask questions, all of
which have been answered in a satisfactory manner. I understand that results can vary and
that no guarantee, neither expressed nor implied, has been or will be given to me regarding
my results. I’m aware of the risks and benefits associated with Micro-needling procedure, as
well as available alternative treatments. I understand that micro-needling is an elective
procedure performed solely for cosmetic purposes and is not critical to my health. Of my own
free will, I am requesting and providing my informed consent to undergo Micro-needling
treatment(s) at _________________. I assume all risks as my own and agree to hold
harmless, _____________________its providers, therapists and any other staff members,
affiliates, and independent contractors. I hereby release them from any liability, both seen
and unforeseen, now and forever.
__Gusan _____________________ ______Tatiana Gusan __ 20/10/21
Client Signature Name (Printed) Date
_______________________ _________________________ _________________
Therapist Signature Name (Printed) Date
Name Tatiana Gusan Date of 23/09/89
Birth
Micro-needling Consultation & Consent Form
Address Dublin 10 Contact 0896574326
14 Bloomfiel Avenue Number
assistance
Doctors Diana Finegan Phone 0897685432
Name: Number:
Doctors Clonee Dublin 15 Client ID B235687982
Address
Before
Photo /
Photo
consent
Purpose of treatment (please circle answers)
ACNE SCARRING AGE SPOTS DEHYDRATED SKIN
LINES/WRINKLES LOOSE SKIN PIGMENTATION
ROUGH/UNEVEN SKIN TEXTURE SUN DAMAGE
Micro Needling Treatment
WOULD YOU DESCRIBE YOUR SKIN AS (please circle answer)
DRY COMBINATION OILY SENSITIVE
HOW WOULD YOU DESCRIBE YOUR STRESS LEVELS (please circle answer)
LOW MODERATE HIGH SEVERE
Please circle which skin care products you are presently using
Micro-needling Consultation & Consent Form
CLEANSER TONER MOISTURISER SERUM
SPF EYECREAM EXFOLIATOR SELF TAN
ENZYME PEELS FACE OIL MAKEUP OTHER
How many years have you noticed this problem? _____________________
At what age did this skin problem occur? ____________________________
Are your present skin problems getting more pronounced Y Yes No
Have you received prior treatment for this problem Yes No
If yes, when? _____________________________________
By what method __________________________________
Treatment series
I certify that all the information given above is true and I have not had any of the following
• Sun Exposure in the last 4 weeks
• Change in medication
• Been under doctors care or supervision
• Any surgery
• Pregnancy /trying to be pregnant or breast feeding
Treatment 1 Signature ________________________Date _____________ Clinician ___________________
Treatment 2 Signature ________________________Date _____________ Clinician ___________________
Treatment 3 Signature ________________________Date _____________ Clinician ___________________
Treatment 4 Signature ________________________Date _____________ Clinician ___________________
Micro-needling Consultation & Consent Form
Treatment 5 Signature ________________________Date _____________ Clinician ___________________
Treatment 6 Signature ________________________Date _____________ Clinician ___________________
Treatment 7 Signature ________________________Date _____________ Clinician ___________________
Treatment Dates Notes/Products used and recommended- needle size , product
applied
Micro-needling Consultation & Consent Form
