Microneedling Intake Form

North Seattle Natural Medicine

617 5th Ave S. Edmonds, WA 98020

Phone: 206-629-5180
Fax: 206-629-5197

Precare Information

For the safety of our patients, we are unable to perform Microneedling if you experience any of the conditions below. Please go through this list thoroughly to ensure the following is NOT applicable:

I do not have active skin cancer in any of the treatment areas.

I do not have open wounds, sores or irritated skin in the treatment areas.

I do not have allergies to stainless steel or tetracaine, lidocaine or benzocaine (anesthetics), hyaluronic acid, purified water, glycerin, carbomer, potassium hydroxide, disodium EDTA, phenoxythanol, crapylyl glycol, or sorbic acid.

I do not have a hemorrhagic (bleeding) disorder nor use blood thinning medications/anticoagulants (such as Warfarin, Coumadin and Heparin).

I am not pregnant or nursing.

I am not currently taking medications with the ingredient isotretinoin (such as Accutane) nor using retinols.

*I DO experience one or more of the conditions above. (Please elaborate below in Medical History section.)

For the safety of our patients, proper Microneedling Precare is critical. Please check to acknowledge that you will practice the correct Precare practices via the following:

On the day of the appointment, I will be sure that all areas receiving treatment are completely clean and free of any makeup/lotion/tanners/perfume/topicals.

If microneedling is scheduled for my face, all makeup has been thoroughly removed including all eye makeup/mascara.

I will wear either a tank top or a loose button up shirt that allows easy access to the treatment areas.

I consent to before/after photos being taken to document my progress and results. These photos will be stored in my HIPAA secure EHR chart and not shared publicly/with any facilities.

Basic Information

First name

Last name

Phone number

Email address

I consent to detailed voice messages being left on my voicemail for my phone number listed above. This permission may be rescinded at any time. Please contact the clinic if you wish to rescind.

Yes

Address 1

Address 2

City

State

Zip code

Date of birth

Age

Preferred gender pronoun(s)

Gender assigned at birth

Male

Female

Please describe

In addition, please list if you are allergic to stainless steel, hyaluronic acid, tetracaine, lidocaine, benzocaine, purified water, glycerin, carbomer, potassium hydroxide, disodium EDTA, phenoxythanol, crapylyl glycol, or sorbic acid.

What areas are you looking to get treated with microneedling?

What are your goals for microneedling (example: acne scar treatment or wrinkles)

Medical History

Do you have any other current medical conditions or symptoms? (Please list)

List the prescription and non-prescription medications, birth control, vitamins, minerals, and herbs that you are currently taking (include the dosage of each)

List any major illnesses, hospitalizations, surgeries, or serious injuries (include date and brief description)

How did you learn of us?

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