Fitzpatrick Skin Type Form
Prospective Client Name
First Name
Last Name
My ethnic origin is close to: (check one)
Very fair(Celtic and Scandinavian)
Fair-skinned Caucasian with light hair and light eyes
Pale-skinned Caucasian with dark hair and dark eyes
Olive-skinned(Mediterranean, some Asian, some Hispanic)
Dark-skinned(Middle easten, Hispanic, Asians, some Africans)
My eye Colour is:
Light Blue
Blue/Green
Green/Grey
Hazel/light Brown
Brown
My natural hair colour at age 18 was:
Red
Blonde
Light Brown
Dark Brown
Black
The colour of my skin that is not normally exposed to the sun is:
Pink to reddish
Very Pale
Pale with a beige tint
Light Brown
Medium to dark brown
Dark brown-black
If I go out into the sunlight for an hour or so without sunscreen and have not been out in the sun for weeks, my skin will:
Burn, blister and peel
Burn, then when the burn resolves there is a little or no colour change
Burn, but then turn to tan in a few days
Get pink, but turns to tan quickly
Just tan
Just gets darker
My skin colour is so dark i cannot tell
When was the last time the area to be treated was exposed to natural sunlight, tanning booths or artifical tanning cream?
Longer than a month ago
Within the past month
Within the past two weeks
Within the past week
Carbon Laser skin rejuvenation - Primary Consultation Form
Personal Details
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
County
Postal Code
Home Number
-
Area Code
Phone Number
Mobile Number
Email Address:
example@example.com
Carbon skin rejuvenation Primary Consultation Forms
If your skin type is a 4 or above the treatment will not be suitable for your skin
Is the area exposed to the sun?
Yes
No
Have you hade a history of Keloids?
Yes
No
Have you had a history of hyper or Hypo-pigmentation/
Yes
No
Details (if Applicable)
Any known Alleries?
Yes
No
Details (if Applicable)
Are you currently taking any medication?
Yes
No
Details (if Applicable)
How would you describe your skin?
Thick
Thin
Saggy
Firm
Normal
Dry
T-Zone/combined
Oily
Acne
Acne scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Uneven/blotchy
Mature
Wrinkled
Patchy dryness
Melasma
Hypopigmentation
Hyperpigmentation
Dehydrated
Telangietasia/brocken surface capillaries
Contraindications Checklist
Please read the following - if anything applyes please enter in next text box.
Enter any information in refeance to above text
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Signature
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