MICRONEEDLING CONSULTATION & CONSENT FORM

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Full Name

Date of Birth

Contact Number

Email Address

Address

Emergency Contact Name

Emergency Contact Number

TREATMENT OVERVIEW

Microneedling (also known as collagen induction therapy) involves creating controlled micro-injuries to the skin using sterile microneedles. This stimulates the production of collagen and elastin, improving skin tone, texture, scarring, fine lines, and pigmentation.
・ Treatment Duration: ~60 minutes
・ Results: Gradual improvement over 3–6 sessions (4–6 weeks apart)

MEDICAL HISTORY

Pregnancy or breastfeeding Active acne, eczema, rosacea, or psoriasis Papulopustular rosacea Autoimmune disorders (e.g., lupus, rheumatoid arthritis) Diabetes or delayed wound healing Bleeding/clotting disorders (e.g., haemophilia) Blood thinners (e.g., warfarin, aspirin) Keloid or hypertrophic scarring tendency Heart conditions or cardiac abnormalities Recent sunburn, skin infection, open lesions Use of Isotretinoin (Accutane) within 12 months History of cold sores (herpes simplex) Recent cosmetic procedures (botox, filler, laser, etc.) Known allergies to topical anaesthetic or skincare products

If any conditions are ticked, please provide details:

Previous cosmetic treatments

SKIN ANALYSIS & CURRENT SKINCARE

What is your skin type?

Dry Oily Combination Sensitive

Are you using any products containing retinoids, glycolic acid, AHA/BHA?

Yes No

Do you regularly exfoliate your skin?

Yes No

Have you had any skin reactions to cosmetic products?

Yes No

Have you had microneedling before? If yes, when?

RISKS & SIDE EFFECTS

Please read each statement carefully and check to confirm your understanding and agreement.

I understand that microneedling involves controlled micro-injuries to the skin to stimulate collagen and elastin production. I acknowledge that common side effects may include redness, mild swelling, skin sensitivity, and pinpoint bleeding. I understand that bruising or mild discomfort may occur during or after treatment I am aware that temporary dryness, tightness, or flaking may occur within a few days post-treatment. I understand that there is a small risk of infection if aftercare instructions are not followed. I understand that hyperpigmentation or allergic reactions are rare but possible. I have had the opportunity to ask questions and all my concerns have been addressed.

POST-TREATMENT AFTERCARE

Please confirm your understanding of the following post-care instructions:

I will avoid touching my face or applying makeup for at least 12 hours after the treatment. I will avoid sun exposure, heat, steam rooms, saunas, or exercise for 48 hours. I will not use exfoliating products, retinoids, acids (AHA/BHA), or strong active ingredients for 5–7 days. I will cleanse gently using a mild product and apply SPF 30+ daily. I understand that I must keep the treated area clean and hydrated. I will contact the clinic immediately if I experience excessive redness, pain, or signs of infection.

PHOTO/VIDEO CONSENT (OPTIONAL)

Please select your preference below:

I consent to before and after photographs being taken for my treatment records. I consent to QT Beauty & Aesthetics using my photographs for marketing purposes (e.g., website, social media). I do not consent to any photographs being taken or used.

CLIENT DECLARATION & CONSENT

Please confirm each point below before signing:

I confirm that all the information I have provided is accurate and complete. I understand the microneedling procedure, its risks, benefits, and alternative options. I confirm I am not under the influence of alcohol, drugs, or medication that may impair my judgment. I understand that individual results vary and that multiple sessions may be necessary for optimal results. I understand that QT Beauty & Aesthetics is not liable for any adverse outcomes if information has been withheld. I voluntarily consent to proceed with the microneedling treatment.

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019-9253-8866
info@qtbeautyandaesthetic.co.uk
31 Fore St, Hertford Hertfordshire SG14 1DJ

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