Skin Needling Consultation Form

Full Name *

First Name

Last Name

Are you happy for us to share your before and afters on social media? *

Yes

No

Have you used any products containing any of the following ingredients? *

Alpha/Beta Hydroxyl Acids (Lactic, Salicylic, Glycolic)

Retinoids (Vitamin A)

Benzoyl Peroxide

Hydroquinone/Kojic Acid/Azaelic Acid

No, none

Skin Needling is not suitable for patients experiencing the following. Please select if applicable to you. *

Papular/Pustular Rosacea

Open Lesions

Acne Vulgaris Stages 3+

Herpes Simplex

Warts

Skin Cancer

Haemophilia

Bacterial/Fungal Infection

Auto-Immune Diseases

Eczema or Dermatitis in the area

Diabetes

Roaccutane treatment less than 6 months ago

Blood thinning medication/blood clotting disorders

Easily bruised

I give my consent to receive treatment. I understand that my skin may be red and feel like moderate sunburn. I consent that I do not suffer from any of the above contraindications and to contact my clinician with any issues relating. I understand a course of treatments will be required for optimal results along with quality skincare. *

Yes, I agree