Skin Consultation Form | Dermal Remedy

skin

consultation form

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

Personal Information

First Name

Email Address

Last Name

Mobile Number

Address

Date of Birth

Occupation

Family Doctor Name

Emergency Contact Name

Are you currently under a doctos care?

Yes

Age

Ethnic Background

Family Doctor Number

Emergency Contact Number

If yes, for what condition/s

List all medication taken

Allergies

Have you been treated for any of the following?

Skin Disease

Acne

Cold Sores

High Blood Pressure

Diabetes

Cancer

Hormone Therapy

Are you pregnant?

Yes

Do you smoke?

Yes

Do you drink alchol?

Yes

If yes, how many a day?

If yes, how many starndard drinks a week?

How much water do you drink a day?

How often do you exercise? What type of exercise do you do?

What is your daily stress level?

Mild/Low

Medium/Average

High/Intense

Do you have any metal implants on your body?

Yes

If yes, where?

Your Skin

On a scale of 1 - 10 (1 = horrible, 10 = fantastic) please rate how you feel about the overall look of your skin

How often do you wear facial sunscreen?

Everyday

Occasionally

Only when I'm outside

When was your last sunburn?

1-2 months ago

Less than a month ago

Less than 2 weeks ago

If you go in the sun without sunscreen, how often will you burn?

Always

Most of the time

Sometimes

Rarely burn

Very rarely

I never burn

Please list any cosmetic procedures you have had within the past 12 months

What skin care line are you using?

Describe your daily skin care routine

What is the most important improvement you would like to see in your skin

Do you receive any of the followin procedures regularly?

waxing

facial injections

microdermabrasion

chemical peels

other

If other, please describe

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?

light blue, gray, green

blue, gray or green

blue

dark brown

brownish black

0

1

2

3

4

What is the colour of your skin in non exposed areas?

reddish

very pale

pale with beige tint

light brown

dark brown

0

1

2

3

4

Whatis the natural colour of your hair?

sandy red

blonde

chestnut/dark blonde

dark brown

black

0

1

2

3

4

Do you have any freckles on unexposed ares?

many

several

few

incidental

none

0

1

2

3

4

Total score for genetic disposition

Reaction to Sun Exposure

What happens when you stay in th sun too long?

painful redness, blistering, peeling

blistering followed by peeling

burns sometimes followed by peeling

rarely burns

never burns

0

1

2

3

4

Do you turn brown with in several hours of sun exposure?

never

seldom

sometimes

often

never burns

0

1

2

3

4

To what degree to you turn brown?

hardly or not at all

light colour tan

reasonable tan

tan very easily

turn dark brown quickly

0

1

2

3

4

How does your face react to the sun?

very sensitive

sensitive

normal

very resistant

never had a problem

0

1

2

3

4

Total score for Reaction to Sun Exposure

Tanning Habits

When did you last expose your body to sun or tanning cream?

over 3 months ago

2-3 months ago

1-2 months ago

less than a month ago

less than 2 weeks ago

0

1

2

3

4

Do you expose the area to be treated to the sun?

never

hardly ever

sometimes

often

always

0

1

2

3

4

Total score for Tanning Habits

Total Score

0 - 7

8 - 16

17 - 25

25 - 30

over 30

Fitzpatrick Type

I

II

III

IV

V - VI

Your Total Score

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

The professional Skin Conditioning Facail + Facial Peel are superficial treatments designed to improve the texture and appearance of your skin. Your participation in your treatment will dertermine the outcome. It is important that you strickly adhere to all instrucitons that your treatment specialist has provided

No guarantee is expressed, or implied as to the precise results, peeling times, or discomfort

Depending on the treatment, you may experience some temporary redness, stinging, or warm flushing. During the next few hours, you may experience some tightening of the skin which may last for several days

For most individuals, a light flaking begins within 48 hours. It is impossible to pre-determine how much peeling will occur

Dark spots may appear darker before shedding off

Depending on the treatment, the shedding process usually subside between 2-7 days

Lack of flaking or peeling is NOT an indication that the treatment of skin tone, texture, and appreance of fine lines and hyperpigmentation. There are a number of reasons whu some people may not experience peeling such as: severe sun damage, having regualar peels with short ineralvals between treatments, and frequent use of Retin A, Retinol, or AHAs

Depending on the treatment performed and your individual skin health, the following reactions may occur in some individuals: prolonged redness, irritation, flakiness, dryness, sensitivity, and in rare instances severe allergic reactions

Individuals who should not be treated

A Skin Conditioning Facial or Facial Peel SHOULD NOT be performed on people with active cold sores or warts, skin with open wounds, sunburn, excessively sensitive skin, dermatitis or inflammatory Rosasea in the area to be treated, or with an autoimmune disease

You should not have these treatments if you have a history of allergies, rashes, other skin reactions, cancer, or may be sensitive to any components of this treatment

This treatment is not recommended if you have taken Accutane (or its genaric form) within the past year, or received chemotherapy or radiation therapy

With the exception of Lira Clinicals Beta-C Plus and Pumpkin Plus Definer with PSC treatments, this treatment should not be administered to pregnant or breast feeding (lactating) woman

*Inform your therapist if you have any of the above concerns, a history of herpes simplex, or are allergic to asprin

Pre Treatment Guidelines

Unless otherwise instructed to do so by your therapist:

One week prior to treatment avoid waxing, electrolysis, laser hair removal, presciption retinoids/retinoid like compounds (retin A, Renova, Differin, Tazorac), products containing Retinol, AHA's, BHA's, Benzoyl Peroxide, or anu exfoliating products that may be drying or irritating on the area to be treated

Individuals who have medical cosmetic facial procedures must wait until skin sensitivity completely resolves before having a Skin Conditioning Facial or Facial Peel

Post Treatment Guidelines

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

It is imperative that you use the prescribed Skin Products to heal and protect the skin which includes mandatory sun protection

Avoid direct sun exposure for at least 48 hours

Your skin may be more sensitive after your treatment so avoid strenous exercise for at least 24 hours

Do not prick or pull the skin

When cleansing do not scrub or use a wash cloth

Wait until flaking and peeling is complete before returning to your regular home care routine or having additional professional treatments

Immediately notify Dermal Remedy of any concerns

Consent

I hereby give my concent + authorisation, and voluntarily release Dermal Remedy from any claims implied or stated that I have or may have in the future with this treatment, regardless of result. I am stating that the treatment and precausions above have been explained to me in detail and that I fully understand. If I am under the care of a physician, I have discussed the treatment plan with my physician for prior approval.

Your Signature

Select a date

Thanks for submitting x

skin

consultation form

Personal Information

Your Skin

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

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

Reaction to Sun Exposure

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

Tanning Habits

0

1

2

3

4

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

Post Treatment Guidelines

Consent