skin
consultation form

to provide you with a very safe service with the best possible results please provide the following information

Personal Information
Are you currently under a doctos care?
Have you been treated for any of the following?
Are you pregnant?
Do you smoke?
Do you drink?
What is your daily stress level?
Do you have any metal implants on your body?
Your Skin
How often do you wear facial sunscreen?
When was your last sunburn?
If you go in the sun without sunscreen, how often will you burn?
Do you receive any of the followin procedures regularly?
Fitzpatrick Skin Type Evaluation
Please answer the questions below.  Tick the appropriate response to each of the items to arrive at a total score.  This will confirm your skin type which will be reviewed at your consultation.
Genetic Disposition
What is the colour of your eyes?
0
1
2
3
4
What is the colour of your skin in non exposed areas?
0
1
2
3
4
Whatis the natural colour of your hair?
0
1
2
3
4
Do you have any freckles on unexposed ares?
0
1
2
3
4
Reaction to Sun Exposure
What happens when you stay in th sun too long?
0
1
2
3
4
Do you turn brown with in several hours of sun exposure?
0
1
2
3
4
To what degree to you turn brown?
0
1
2
3
4
How does your face react to the sun?
0
1
2
3
4
Tanning Habits
When did you last expose your body to sun or tanning cream?
0
1
2
3
4
Do you expose the area to be treated to the sun?
0
1
2
3
4
Total Score
0 - 7
8 - 16
17 - 25
25 - 30
over 30
Fitzpatrick Type
I
II
III
IV
V - VI
The instructions and guidelines provided in the informed consent should be followed by all individuals recieving a Professional Skin Conditioning Facial and Facial Peel.
Please read and initial after each paragraph acknowledging that you have read and understood all of the information presented.
Professional Skin Conditioning Facial + Facial Peel Treatment
Individuals who should not be treated
Pre Treatment Guidelines

Unless otherwise instructed to do so by your therapist:

Post Treatment Guidelines

It is crucial to the health of your skin and success of your treatment that these guidelines be followed

Consent

Your Signature

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