Email Address: Laritz1234@gmail.com

Phone Number: (770) 918-1380 Toll Free: (833) 953-1380

Address: 905 Flat Shoals Rd SE, Conyers, Ga 30094

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Microneeding Consultation Form

Microneeding Consultation Form

Kindly Complete the Microneeding Consultation Form

Download PDF Consent Form

Full Name*

Email Address*

Phone Number*

Date*

Age*

Gender*

Birthdate*

Complete Address*

How did you hear about us?

Emergency Contact Info

Emergency Contact Info

Name*

Phone Number*

Area(s) to be treated today?

Please list past or present medical conditions, illnesses, or allergies*

Present Medications (i.e. Accutane, antibiotics, aspirin, antiviral, iron supplements, Gold therapy, Coumadin, fish oils, herbal supplements, prescribed topical creams) Please list all medications, dosages, and date last taken*

Do you have a history of any autoimmune disease? (i.e. Diabetes, Lupus, Rheumatoid Arthritis, Celiac) If so, please list*

Do you have any tattoos? If so, please list location(s)

Are you or could you be pregnant? (If yes, indicate how many months)

Do you have a history of keloids/hypertrophic scars?*

Tanning history (direct sun, self-tanners, spray tans) – Please list and include last date of use

Previous Laser Treatment(s) - If known, please specify date, number of treatments, frequency, response to treatment, device used

Previous hair removal history (Check all applicable)

Waxing

Plucking

Electrolysis

Bleaching

Shaving

Have you ever had a cosmetic peel or any other cosmetic procedure? If so, please list and include date of last treatment

Do you have a history of skin cancer or mole removal?*

Do you suntan?*

Do you use sunscreen?*

Do you smoke?*

Please list the brand of products you are currently using (Check all applicable)

Cleanser

Toner

Moisturizer

Eye Cream

Mask or Scrub

Sunscreen

Others

Please list the brand of products you are currently using (Check all applicable)

Have you ever used skin lightener or Retin-A?*

If yes, please list date of last usage

Please check any of the following skin concerns you may have*

Wrinkles

Scarring

Spider Veins

Ingrown Hairs

Skin Tone

Black Heads

Rosacea

Acne

White Heads

Hard Bumps Under the Skin

Others

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Email Address: Laritz1234@gmail.com

Phone Number: (770) 918-1380

Toll Free: (833) 953-1380
Mon-Sat: 10:00am-7:00pm, Sunday: Closed

Address: 905 Flat Shoals Rd SE, Conyers, Ga 30094

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