Clinic template
Microneedling consent form template (UK)
Free microneedling consent form template for UK clinics. Contraindications, needle depth record, risk acknowledgements and signature blocks.
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Version 2026-04-29. Adapt it for your clinic before use. Read the full HTML document.
- Audience
- Qualified aesthetic practitioners
- Available now
- Full HTML and a copyable text version, plus PDF and Word downloads
- Scope
- UK practice. Check the requirements where you practise.
- Before use
- Adapt the wording and check it with your insurer.
For qualified practitioners: a template to adapt, not clinical advice.
Use your clinical judgement for every patient. Check the products you use, your protocols, manufacturer instructions, your prescriber's directions where relevant, and your insurer's requirements.
The template
Patient details
Full name: ___________________________
Date of birth: ___________________________
Phone: ___________________________
Email: ___________________________
Address: ___________________________
Treatment details
Device (pen/roller, make and model): ___________________________
Area(s) to be treated: ___________________________
Needle depth (mm): ___________________________
Topical anaesthetic used (product, if any): ___________________________
Number of sessions planned in this course: ___________________________
Date of treatment: ___________________________
About this treatment
Microneedling uses fine needles to create controlled micro-injuries in the skin, stimulating collagen and elastin production. It is used for skin texture, acne scarring, fine lines and enlarged pores. A course of treatments spaced several weeks apart is usually recommended; visible improvement develops gradually over the following weeks and months. No specific outcome can be guaranteed.
Contraindications and screening
Please confirm each of the following:
- I do not have active acne, infection, eczema, psoriasis or broken skin in the treatment area
- I am not currently taking isotretinoin (Roaccutane) and have not taken it in the last 6 months
- I do not have a history of keloid or hypertrophic (raised, abnormal) scarring
- I do not currently have a cold sore, and I have told my practitioner if I have a history of cold sores
- I am not pregnant and not breastfeeding
- I do not have a bleeding disorder and have disclosed any blood-thinning medication or supplements
- I have disclosed any recent sunburn, sunbed use, chemical peel or laser treatment in the area
- I have disclosed all skincare actives I use (retinoids, acids, exfoliants)
Risk acknowledgement
I understand and accept the following recognised risks of microneedling:
- Redness, warmth and a sunburn-like feeling, usually settling within 24 to 72 hours
- Swelling of the treated area
- Pinpoint bleeding and bruising during and shortly after treatment
- Dryness, flaking and temporary skin sensitivity
- Infection if the area is not kept clean while healing
- Pigmentation changes (darkening or lightening of the skin), a higher risk with sun exposure after treatment and in deeper skin tones
- Reactivation of cold sores in patients with a history of herpes simplex
- Allergic or irritant reaction to topical anaesthetic or products applied during treatment
Aftercare commitment
- I agree to follow the written aftercare instructions, including keeping the area clean, avoiding make-up for 24 hours, avoiding active skincare for the advised period, and using high-factor sun protection daily while the skin heals.
Photography
- I consent to clinical photographs being taken before and after treatment for my confidential patient record.
- I additionally consent to my photographs being used for marketing purposes (optional).
Outcome
- I understand that results develop gradually, vary between individuals, usually require a course of treatments, and cannot be guaranteed.
Patient declaration
I confirm that I have read and understood the information above, that I have had the opportunity to ask questions and that they have been answered to my satisfaction. The information I have given is true and complete. I consent to microneedling treatment as described.
Patient signature: ___________________________
Print name: ___________________________
Date: ___________________________
Practitioner declaration
I confirm that I have explained this procedure to the patient, including its intended benefits and material risks, and any available alternative treatments, and that the patient has had the opportunity to ask questions.
Practitioner signature: ___________________________
Print name and qualification: ___________________________
Date: ___________________________
This template is for UK aesthetics practitioners offering microneedling (collagen induction therapy), whether by pen or roller. Microneedling is sometimes treated as a low-stakes treatment that does not need rigorous paperwork. That is a mistake: pigmentation changes, infection and cold sore reactivation are all recognised complications, and isotretinoin use and keloid history are genuine contraindications that must be screened in writing. A defensible consent form is informed, specific (device, depth, area), signed by patient and practitioner, versioned and retrievable on request.
Why each section exists
The screening questions do most of the protective work on this form. A patient on isotretinoin, with an active breakout, or with a history of keloid scarring should not be needled, and a signed answer to each question protects the practitioner who relied on it. The cold sore question matters because needling can reactivate herpes simplex across the treated area, which is a far larger problem than a single lip lesion.
The needle depth field is the detail most paper forms miss. Depth determines both the clinical effect and the risk profile, and recording it per treatment gives you a defensible account of exactly what was done if an outcome is ever questioned. It also makes your treatment plan reproducible across sessions and practitioners.
England’s planned licensing scheme for non-surgical cosmetic procedures signals that written consent and complete treatment records will become baseline requirements across the sector, including for device-led treatments like microneedling. Insurers already expect itemised risk disclosure and evidence of screening; this template gives you both.
Using it in practice
Copy the template onto your own letterhead, fill in the device you actually use, and date the version so every signature can be matched to its exact wording. Complete the needle depth field at the time of treatment, not afterwards, and carry the same details across to a treatment record so each session in a course is individually documented. Screen new patients with a full medical history form before the first session.
AesthetiClinic takes the admin out of this entirely: the consent form goes e-signed to the patient’s phone before the appointment, wording changes are versioned automatically, and the signed document files itself on the patient record. See the features page.
Written aftercare should go home with every patient; our microneedling aftercare guide is a ready starting point, and all the free documents live in the template library.
This template is provided as a starting point for UK aesthetics practice. It is not legal or medical advice. Review the wording with your insurer and, where relevant, your prescriber before use.
Before you use it
Adapt it for your clinic.
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Use your own details.
Name your clinic and the products and services you actually provide. Replace every placeholder before use.
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Review the wording.
Check the final form against your protocols, your prescriber's directions where relevant, and your insurer's requirements.
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Keep the version.
Date the final document and keep the exact wording used. Review it when your services, products or terms change.
Send forms to the patient's phone, capture an e-signature and keep the signed record.
See consent forms softwareCopy this template for your clinic.
Copy the full text into your own document and adapt it. Check the final wording with your insurer.
This action copies text.
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Sources and corrections
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