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Microneedling Consent Form Template

A printable microneedling consent form covering screening, what to expect in the days after treatment, the risks, and the aftercare rules that protect the result.

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Last reviewed September 2026 · Not legal advice

Part of the Microneedling treatment guide →

Be specific about the days after

Microneedling causes controlled injury by design. The form should describe what clients will see, such as redness like sunburn, dryness, and flaking, and for how long, and what they should avoid: makeup, active skincare, exercise, and sun.

Screening should cover active skin conditions, isotretinoin use, bleeding disorders, keloid tendency, and pregnancy. Record the answers, not just the signature.

Clinic name · address · phone

Microneedling Consent Form

Client

Full name

Date of birth

Phone

Screening

Pregnant or breastfeeding? Yes No

Isotretinoin in the past 12 months? Yes No

Active acne, eczema, infection, or cold sore in the area? Yes No

Bleeding or clotting disorder, or on blood thinners? Yes NoIf yes, details

Keloid or hypertrophic scarring? Yes No

Previous microneedling? Yes NoIf yes, details

Risks and acknowledgements

Initial each item to confirm you have read and understood it.

InitialsI understand redness, swelling, tightness, and flaking are expected for several days.

InitialsI understand risks include infection, pigment change, scarring, and reactivation of cold sores.

InitialsI agree to avoid sun, makeup, active skincare, and strenuous exercise as instructed.

InitialsI understand that results develop gradually across a series.

InitialsI have disclosed all relevant medical history and medications.

Consent

I have had the chance to ask questions
I received aftercare instructions
I consent to treatment

Signatures

Client / patient signature

Date

Practitioner name and signature

Date

Template from zdrovia.ca/templates/microneedling-consent-form/ · Review with your medical director, regulatory college guidance, and insurer before use.

Send this form before the appointment instead of printing it

Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.

Start free, no card required See how digital forms work →

See how Zdrovia is set up for aestheticians.

Frequently asked questions

Should the form list expected redness and flaking?

Yes. Naming expected effects reduces alarm and unnecessary calls.

Does PRP need a separate form?

Yes, because it involves a blood draw and its own risks.

This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.