Free Skin Revision Skin Care Assessment Form Template

Skin Revision Skin Care Assessment Form

Kindly fill out the required details below to ensure a comprehensive and personalized skin care assessment.

Client Information

Name

    Phone number

      Email

        Address

          Medical History

          Do you have any known allergies?

          Are you currently taking any medications?

          Do you have a history of the following

            • Acne

            • Rosacea

            • Psoriasis

            • Eczema

            • Hyperpigmentation

            Are you currently pregnant or breastfeeding?

            What are your primary skin concerns?

              • Fine lines/wrinkles

              • Uneven skin tone

              • Dryness

              • Oiliness

              • Acne

              • Sensitivity

              What is your skin type?

                • Normal

                • Dry

                • Oily

                • Combination

                Consent and Acknowledgment

                By signing below, I confirm that the information provided above is accurate to the best of my knowledge. I understand that this form will be used to create a personalized skin care plan and agree to adhere to the recommendations provided by the skincare professional.

                Date:

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