Microneedling & BB Facial - Mary Beauty Clinic

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Microneedling & BB Facial Form

Step 1 of 15

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Name(Required)

First Last

Date of Brith(Required)

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Relation To Client(Required)

Contact Number (Mobile)(Required)

Contact Number (Land Line)

Email

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FirstLine Second Line City Post Code

Occupation(Required)

Do You Have WhatsApp?(Required)

Yes

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Best Way to Contact You?(Required)

Call

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Please read and complete this form carefully.

Please indicate your answer by checking one box per question and provide detail where appropriate.

To the client:

You have the right to be informed about the procedure(s) to be administered, including benefits, risks, and potential side-effects, so that you can decide whether to proceed. You are encouraged to ask any questions you may have and to consult with a therapist if you have additional questions.

1.Are you pregnant or breastfeeding?(Required)

Yes

No

Please Explain:

(During the pregnancy and breastfeeding you are not allowed to do any microneedling treatment.)

2.Are you prone to keloid scarring?(Required)

Yes

No

3.Are you currently or have you taken any medication containing Isotretinoin (e.g. Roaccutane) within the past 12 months?(Required)

Yes

No

Please Explain:

4.Do you have any active infections-viral, fungal, bacterial?(Required)

Yes

No

Please Explain:

5.Do you have any rashes or moles on the treatment area?(Required)

Yes

No

Please Explain:

6.Have you ever had skin cancer?(Required)

Yes

No

Please Explain:

7.Do you have any skin disease or condition such as Eczema?(Required)

Yes

No

Please Explain:

8.Do you have lupus?(Required)

Yes

No

Please Explain:

9.Do you have any skin related autoimmune disorders?(Required)

Yes

No

Please Explain:

10.Do you have any active acne in your treatment area?(Required)

Yes

No

Please Explain:

11.Do you have any conditions that could affect your immune system e.g. Hepatitis C Virus (HBC), Hepatitis B Virus (HBC), AIDS, HIV infection?(Required)

Yes

No

Please Explain:

12.Are you currently on any form of immune suppressant therapy that may cause delayed healing e.g. Chemotherapy, radiation?(Required)

Yes

No

Please Explain when was your last Session:

(To do any needling treatment should pass 6 weeks from your last session.)

13.Do you have any neurological disorders such as Epilepsy, Bell’s palsy, MS, Chorea or Myasthenia Gravis?(Required)

Yes

No

Please Explain:

14.Do you have any allergies such as latex, lidocaine, antibiotics, food, drugs / substances?(Required)

Yes

No

Please list:

15.Are you allergic or sensitive to any local or topical anaesthetic (including dental anaesthetics)?(Required)

Yes

No

Please Explain:

16.Are you sensitive to any regular makeup, hair dyes or any other dyes?(Required)

Yes

No

Please Explain:

17.Do you have any Asthma or other allergic disease?(Required)

Yes

No

Please Explain:

18.Do you carry a warning card, Epi pen, had anaphylaxis reaction?(Required)

Yes

No

Please Explain:

19.Have you ever had a cold sore?(Required)

Yes

No

Please contact to your physician for preventative prescription capsule to prevent a cold sore.

20.Do you have or have you ever had any heart or blood pressure problems?(Required)

Yes

No

Please Explain:

21.Do you have blood-borne disease?

Yes

No

Please Explain:

22.Do you have a stroke or any other blood pressure problems?(Required)

Yes

No

Please Explain:

23.Do you have Angina, Murmur, Valve or other heart condition?(Required)

Yes

No

Please Explain:

24.Are you take any blood thinners, both prescription and over the counter?(Required)

Yes

No

Please Explain:

25.Are you currently taking any medication to treat the following, which may affect blood coagulation during the Microblading procedure?

Sleeping Pills

Blood Pressure Medication

Hormone Replacement

Antibiotics

Tranquilizers

Painkillers (Aspirin/Ibuprofen)

Fainting/Dizzy Spells

Diabetes

Cortisone (Inhaler/cream)

26.Are you currently taking any medication?(Required)

Yes

No

Please list any medication you have been taking in the last 6 months, both prescription and over the counter:

27.Do you have any neurological disorders such as Epilepsy, Bell’s palsy, MS, Chorea or Myasthenia Gravis?(Required)

Yes

No

Please Explain:

28.Do you have any endocrine disorders such as Diabetes or Thyroid?(Required)

Yes

No

Please Explain:

29.Do you have any chronic medical conditions?

Yes

No

Please Explain:

30.Have you had any cosmetic procedures such as dermal fillers, fillers, reconstruction?(Required)

Yes

No

Please List:(Required)

When

Less than 1 month

Less than 3 months

Less than 6 months

Less than 1 year

More than 1 year

31.Have you had any aesthetic procedures?(Required)

Yes

No

Choose

Laser

Skin exfoliation

Skin peeling

Dermabrasion

Gold wire

Ultrasound

other

other

When

Less than 1 month

Less than 3 months

Less than 6 months

Less than 1 year

More than 1 year

32.Have you had any aesthetic surgery such as liposuction, nose job, jaw, hair transplant, breast augmentation, etc.?

Yes

No

Please Specify

Less than 1 month

Less than 3 months

Less than 6 months

Less than 1 year

More than 1 year

33.Did those previous aesthetic procedures cause any undesirable reactions?(Required)

Yes

No

Please Specify:

34.Do you have an eye disease?(Required)

Yes

No

Please Explain:

35.Have you had healing problem after surgery or trauma?(Required)

Yes

No

Please Specify:

36.Do you have any recent vaccinations, cortisone injections or steroids?(Required)

Yes

No

Please Specify:

37.Do you use therapies/supplements such as St. John's Wort?(Required)

Yes

No

Please Specify:

Microneedling Procedure

Microneedling is a cosmetic procedure. It involves pricking the skin with tiny sterilized needles. The small wounds cause your body to make more collagen and elastin, which heal your skin and help you look younger. You might also hear it called collagen induction therapy.

Side Effects

After the procedure the skin will be red and flushed in appearance similar to a moderate sunburn. You will experience a feeling of tightness and possibly a mild irritation to the skin that will diminish over the next few hours. It is not common but occasionally mild bruising can occur depending on the depth the needles being used. Peeling and dry skin is common for up to a week afterwards as skin cells are turning over and new ones are surfacing. Very rarely clients will experience minimal scabbing.

Microneedling post procedure instructions

Your skin will be temporarily sensitized after the treatment and you should adhere to the following instructions for the next five to seven days. This will help avoid infection and will allow time for the skin to recover.

Refrain from:

Touching the treated area
Using soaps, cleansers, creams or make-up on the treated area for 5 days
Facial treatments - including eyelash or eyebrow tinting or tweezing, electrolysis. waxing etc.
Any abrasive products, rough towels or similar
DO NOT TOUCH or PICK the small scabs that may appear after the treatment. Healing will take up to one week, and it is perfectly normal for the treated area to scab/flake. These scabs/flakes will fall off within a few days.
Taking hot baths, saunas, or any other heat treatments. The treated area should be kept as dry as possible.
Sunbathing, using sun beds or swimming
Using any form of bleach or depilatory products
Should an infection occur, seek medical attention
Expose the treated area to UV rays
Use make-up other than the recommended after care products
Going for any Laser or IPL treatments

Microneedling Consent form(Required)

I understand that results may vary between individuals.

I understand that although I may see a change after my first treatment.

I understand I may require a series of sessions to obtain my desired outcome.

The procedure and its side effects have been explained to me. I understand the benefits and disadvantages of this procedure.

I am advised that although goods are expected, the possibility and nature of complications cannot be accurately advised and there can be no guarantee expressed or implied to the success of the treatment. I am aware that the Dermal pen microneedling treatment is not permanent and that natural degradation will occur over the time.

I agree that I have read (or it has been read to me), I understand this consent form and the information contained in it.

I have had the opportunity to ask any questions about the treatment, including risks, and I acknowledge that all of my questions about procedure have been answered to my satisfaction.

I understand that this procedure is purely elective.

Terms of Service(Required)

I Understand that I am responsible for notifying the beauty therapist if any of the information should change before treatment.
I confirm that the information is true to be best of my knowledge. I have been fully informed about the expected results and effects of my treatment and agree to follow all aftercare advise provided by therapist. I acknowledge that all information is confidential and will be held on file for 7 years, being solely for the purpose and use of my therapist. I hereby give my consent to proceed with treatment.
I understand and agree that all services rendered are charged directly to me and I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks.
Under fake not to make a claim against the therapist and salon and do hereby indemnify and hold the said business, its Owner and Employees harmless in respect of any claim or damage suffered by me in the consequence of undergoing the treatments procedure.

I agree to the Terms of Service

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March 8, 2025

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