PerfectSkin Aestheticstt
Skin Consultation Form. Start Your Journey To Glowing Skin
Client's General Information
Client's Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Referred by :
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SKIN HEALTH HISTORY INFORMATION
Start Your Journey To Glowing Skin
Have you ever had a professional facial treatment done?
Yes
No
If yes, where was your last professional facial done?
Have you even use Medical grade skincare products or was given a customized At-home Skincare Regimen?
Yes
No
If yes, Please state what medical grade skincare products you are currently using.
Please describe your current at-home skincare regimen
Do your wear SPF
YES
NO
Do you pick and do any at-home extractions on your skin?
YES
NO
Have you ever use any of the following active ingredients in your skincare regimen
Lactic Acids
Glycolic Acids
Mandelic Acids
Salicylic Acids
Citrus Acids
Tartaric Acids
Retinoic Acid
Retin A
Tretinoin
Hydroquinone
Accutane
Please choose the following skin issues + concerns you are currently experiencing
Aging/wrinkles/deep expressions lines/crowfeets
Dullness/Dehydration
Dark circles around the eyes and mouth
Acne/cystic/hormones
Hyperpigmentation/ Stubborn Dermal hyperpigmentation/Post inflammatory
Enlarged pores/ Uneven skin tone
Redness/hypersensitive
Give a brief description of the skincare results you will like to achieve
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Medical History
Start Your Journey To Glowing Skin
Are you on Birth Control?
YES
No
If yes, please list
Are your currently pregnant?
Yes
No
Are you currently trying to get pregnant?
Yes
No
Are you currently on any prescription medications?
Yes
No
Do you have/feel any of the following symptoms
Dizziness
Hypertension [high blood pressure]
Heart issues
Claustrophobic
Photophobia
Diabetes
Epileptic seizures
Anemia [low blood count]
Hypotension [low blood pressure[
Do you have any allergies that you are aware of?
Yes
No
If yes, please list
Do take any daily vitamins or supplements
YES
NO
If yes, please list
Are you on any specific diet?
Yes
No
Do you consume coffee, tea or soda daily?
YES
NO
Do you smoke?
YES
NO
Do your experience cold sores?
YES
No
Have you undergone any medical surgeries in the past 3 years
Yes
No
If yes, please state what surgery and date.
Do you have any metal implant?
Yes
No
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Occupational History
Start Your Journey To Glowing Skin ✨️
Does your job require you to spend long hours in the sun?
Yes
No
Does your job requires you to wear a face mask for more than 4 hours per shift?
Yes
No
Are you required to handle strong chemicals at home/work
YES
NO
Do you engage with members of the public during your working hours
Yes
No
Do you work in a dusty or environmentally unfriendly area?
Yes
No
How would you rate your stress level and a daily basis
Low
Moderate
High
Extreme
Are you a physically active person/Do you play sports
Yes
No
Sometimes
Do your give permission to receive Corrective Skincare Treatments by PerfectSkin Aestheticstt ?
Yes
No
Signature
Submit
IMPORTANT 30mins Virtual Skin Consultation Requirements
Thank you for completing the PerfectSkin Aestheticstt Skin Consultation form for your virtual Skin Consultation please forward four photos of your face [front, both sides and under chin area] for analyzing to 271-7982
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