Microchanneling Intake Form

Action Required: Please fill out the form below before our first treatment

ATTN: Please use the same email and phone number you used to book your treatment

Personal Information

First Name *

Last Name *

Email *

Date of birth *

How did you here about us?

Are you taking any medications or steroids? If yes, please list. *

Are you currently being treated by a dermatologist? If yes, what for? *

Are you pregnant or nursing? *

Yes

No

Have you had a chemical or Laser peel? If so, when? *

Please indicate any of the following that apply to you: *

Heart Condition

Hepatitis

HIV

Cold Sores

Smoker

Keloid Above Neck

Allergy to Steel

Accutane in the last 2 yrs

Diabetes (uncontrolled)

Chronic Skin Disease

None of the above

Have you had botox, filler, PRP or threads within the past 4 weeks? *

Yes

No

Do you have trouble healing? *

Yes

No

Do you have any allergies or sensitivities? *

Yes

No

Not sure

Are you currently using any Vitamin A or E products or Accutane, Retin-A, AHAs/exfoliating skincare? *

Yes

No

Are there any other conditions that may affect the treatment that are not listed above? If yes, please list *

By signing below, I agree that all the information above is true and I agree to use electronic records and signatures.

Signature *