Skin Analysis And History Form Skin Analysis And History Form Please circle your answer: What is your skin type? NormalOilyDryCombination Your skin is ResilientSensitiveUnknown Elasticity: ExcellentGoodFairPoor Acne Stage: IIIIIIIV Fine Lines: Stage 1 – NoneStage II – Wrinkles in motionStage III – Wrinkles at restStage IV – Mostly Wrinkles Circle any of the following words which describe your skin: ThickThinTexturedMiliaAge SpotsLooseFirmUnevenFine LinesRednessWrinkledAcne-proneCystic AcneSallowDehydratedSun-damagedFreckledRosaceaPsoriasisLarge Pores How frequent is your sun exposure? NeverLightModerateExcessive What type of foundation do you use? NoneLiquidCreamPowder How does your skin heal? FastSlowScars Do you bruise easily? YesNo What would you like to achieve from your treatment today? Do you use any kind of acne medication? YesNo Have you had any collagen or Botox in the last 2 weeks? YesNo Consent Acknowledgment I voluntarily consent to receive a facial treatment and understand that facials are for cosmetic purposes only and are not a substitute for medical treatment. I have disclosed all relevant medical conditions, skin history, and sensitivities that may affect my treatment. I understand that withholding medical information may increase the risk of adverse reactions. I understand that certain skin conditions and medications may affect my results and that my face specialist may modify or decline treatment if necessary for my safety. I acknowledge that facials may cause temporary redness, irritation, or breakouts, as my skin adjusts to treatment. I will follow the recommended aftercare instructions. I release the facial specialist/service provider Brooke Bynum at Diamond Salon from any liability resulting from my facial treatment, including unforeseen reactions, irritation, or other side effects. I understand that results vary depending on my skin type, condition, and home skincare routine. No guarantees are made regarding treatment outcomes. I acknowledge that professional skincare treatments may involve extractions, exfoliation, or facial massage and that mild discomfort may occur. I am at least 18 years old (or have a parent/guardian’s consent if under 18). Sign: Date:
