Microneedling Medical Intake Form 1. First Name * 2. Last Name * 3. Address * 4. Apartment / Suite (optional) 5. Email * 6. Phone # * 7. Gender (select one) * MaleFemaleNon-BinaryGender Diverse 8. Birthday * 9. Emergency Contact Name & Phone Number * 10. Were you referred by someone? 11. What is your occupation? * 12. Are you currently pregnant? * 13. Any existing or recent illness? * 14. Any recent hospitalization or surgery? * 15. Please list the names of any medications you are taking: * 16. Are you taking any of the following medications? * InsulinBlood pressure medicationsWarfarinAspirin dailyBirth control or IUDHomeopathic remediesNone of the above 17. Do you have any of the following allergies or sensitivities? * Stainless steel / metal allergyPolysporin or topical antibioticAlcoholNone of the above 18. Please indicate any other allergies: * 19. Have you had any aesthetic procedures in the treatment area within the last 6 months? * 20. Which of the following conditions apply to you? (check all that apply)? * Under 18 years of agePregnant or breast-feedingHistory of cancer (especially skin cancer), or pre-malignant moles in the treatment areaChemo-therapy or radio-therapy within the last 6 monthsAny recent use of Accutane®, Retin-A®, or other medications that exfoliate or thin the skin within the last 6 monthsSevere recurrent conditions such as cardiac disorders, seizures, or autoimmune diseasesBlood thinners or other medications that might impair blood-clottingRecent cosmetic surgery or other medical aesthetic procedures such as laser, IPL, micro-needling, deep/medium chemical peels, or dermabrasion within 3 months of the treatment (or before complete healing)Recent cosmetic facial treatments, injectables (Botox®, fillers, etc.), dermablading/dermaplaning, or non-invasive skin tightening within 3 weeks of the treatment (or before complete healing)Any active conditions in the treatment area such as herpes, cold sores, irritation, active infections, psoriasis, eczema, rashes, or open woundsActive acne or rosaceaSkin growths, lesions, or spider veins in the treatment areaHistory of keloid scarring, abnormal wound healing, or very dry/fragile skinHistory of post-inflammatory hyperpigmentationEndocrine disorders such as diabetesTattoos or permanent make-up in the treatment areaHormone replacement therapyDeficient immune system due to immuno-suppressive disease or medicationsFreshly tanned or sunburnt skin within the last 2 weeksCOVID-19 or other infectious disease symptomsNone of the above 21. Do you have medical insurance? * Cancellation Policy The appointment time you have chosen is the fee you will be charged. The ways you can reschedule or cancel your appointment are: 1. Online through scheduling system or ("View My Appointments") 2. By telephone (time-stamped) at 902-478-7393 up to 48 hours before your appointment. After this time passes your credit card is automatically charged or an invoice issued. Same applies to no-show appointments. Appointments must be paid before the commencement of your next treatment. Forms or requests (other than this one) are not monitored (e.g. e-mails or messages sent through Facebook or other social media sites will not be accepted as a cancellation request). Thank you. I confirm that the provided information is correct and accurately describes my medical history and current health condition. And I hereby give consent to the processing of my personal data.
