Microneedling Intake Form

A microneedling intake form is the first record you complete — before you decide whether to treat. It gathers the client’s information so you can screen properly and make a decision that is within your scope. It collects information; it does not diagnose for you, and it is not a legal shield.

What a microneedling intake form should capture

• Identity & contact details needed for care and follow-up.
• Medical history: relevant conditions such as diabetes control, bleeding or clotting risk, and immune status — recorded and assessed, not excluded on a diagnosis label alone.
• Medications: blood thinners, current or recent isotretinoin, systemic steroids or immunosuppressants — recorded and assessed against the device guidance and, where needed, the prescriber. Never advise a client to stop prescribed medication for a cosmetic procedure.
• Allergies: ask and document (nickel, latex, anaesthetic where relevant).
• Skin history: previous PIH or melasma, past procedure reactions, current actives (retinoids, acids), recent treatments, sun exposure, and the concern being treated.
• Pregnancy or breastfeeding, for which elective microneedling is commonly deferred.

What it does — and does not — do

The form collects the information; you interpret it and decide to decline, defer, refer or proceed. A completed form does not make an unsuitable treatment suitable and does not remove your duty of care. See how to screen: decline, defer, refer or proceed.

Where it fits

The intake form is step one. Consent, the treatment record and aftercare follow. For the full system and why each record matters, read Why You Need Microneedling Intake Forms. Store health information under POPIA: collect only what you need, keep it secure, and follow a lawful retention and disposal process.