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Body Areas Treated
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Last microneedling treatment?
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Performed By
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Skin findings during/after treatment
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Maximum Depth used during treatment
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Skin Pen Facial Lotions Provided to patient?
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Post Care Instructions Reviewed
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Post Care Instructions
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Additional Treatment Notes
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Conversation Notes
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Do you have any allergies?
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If yes what kind?
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Have you had Laser Resurfacing within the last 6 months?
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Have you had a Chemical Peel – within the last 4 weeks
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Have you used Tretinoin (Retin –A, Renova) within the last 2 weeks
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Have you used used Oral isotretinoin/Accutane – within the last 6 months
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Do you have permanent makeup or implants?
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On Anticoagulants?
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Autoimmune Disorder (Lupus, Vitiligo, Scleroderma)?
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Have you had unprotected sun exposure (including tanning beds and fake tan creams) in the last 4 weeks?
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Do you have have history or active Herpes I or II – in the areas to be treated
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Do you have any open lesions in the areas to be treated
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Do you have any active infections?
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History of eczema, rosacea, or psoriasis?
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History of immunosuppression?
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History of Acne?
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History of Uncontrolled Diabetes?
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History of Liver disease or hepatitis?
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Dermal Fillers or Botox within past 10 days?
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Scars <6 months old to area to be treated?
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Risks/Benefits Reviewed and questions answered
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