Skin Microchanneling Consent and Intake Form
Please complete this form to help us understand your needs and ensure a safe, comfortable skin microchanneling experience. Your responses will assist us in tailoring your treatment and confirming your acknowledgment of important information.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What area(s) are you interested in treating?
*
Face
Neck
Décolletage
Hands
Other
What are your main skin concerns?
*
Fine lines & wrinkles
Acne scars
Uneven skin tone
Large pores
Texture/roughness
Hyperpigmentation
Other
Have you had any skin treatments in the past 6 months? (e.g., peels, lasers, injectables)
*
Yes
No
Please list any topical products you regularly use (e.g., retinol, vitamin C, exfoliants)
Do you have any of the following? (Check all that apply)
*
Active acne or open wounds
History of keloid scarring
Recent sunburn
None of the above
I acknowledge that I have read and understood the information provided about skin microchanneling, and I consent to proceed with the treatment.
*
I acknowledge and consent
I do not consent
Is there anything else you would like us to know?
Submit
Should be Empty: