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Holistic Microneedling Intake Form

Select all that apply:
Select all that apply:
Please read and select that you agree to the statements below:

By signing below, I agree to the following:


I have completed this form to the best of my ability and knowledge. I agree to inform the Licensed Acupuncturist of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the Licensed Acupuncturist of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my Licensed Acupuncturist for any injury or damages incurred due to any misrepresentation of my health.

Thank you for submitting your intake. Your email confirmation will be arriving soon. We look forward to reviewing your information and providing your individualized treatment!

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