Microneedling Consultation Form Template

A microneedling consultation form collects skin history, health information, and contraindication screening data from a client before a microneedling procedure. It helps practitioners assess suitability, identify risk factors, and confirm informed consent before treatment begins.

Microneedling is a medical-grade treatment with specific contraindications. A structured intake form ensures no critical health factors are missed, creates a documented record of client disclosure, and gives the practitioner a basis for adapting or declining the treatment when necessary.

Prioritize safety screening alongside skin goals. Key questions include:

• Active skin conditions (acne, rosacea, eczema, psoriasis)
• Current medications, especially blood thinners, retinoids, or antibiotics
• Recent cosmetic treatments (Botox, fillers, chemical peels, and timing)
• History of keloid scarring or poor wound healing
• Autoimmune conditions or immunosuppression
• Pregnancy or nursing status
• Skin concerns and treatment goals
• Previous microneedling or skin-needling experience

Use conditional logic to route high-risk responses to a specific message directing the client to seek physician clearance before the appointment. Configure a notification so you're alerted immediately and can follow up before the appointment date.

A new form should be completed before each treatment course, not just the first. Medications, skin conditions, and health status change. A brief update form before each session — rather than a full intake every time — captures material changes while respecting the client's time.