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Skin Analysis FormWebM2026-06-16T10:47:53+10:00

Skin Analysis Form

Ultraformer MPT Patient Consent Form

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CLIENT DETAILS

Client Name(Required)

Consultation Date

Email

Consultation Date

Practitioner

PRESENTING CONCERNS

Presenting Concerns

Ageing / Fine Lines

Wrinkles

Pigmentation

Melasma

Sun Damage

Acne

Acne Scarring

Rosacea

Sensitive Skin

Enlarged Pores

Dehydration

Skin Laxity

Double Chin

Jowls

Uneven Skin Tone

Other

If Other, please specify

FITZPATRICK SKIN TYPE

Fitzpatrick Skin Type

Type I – Always Burns, Never Tans

Type II – Usually Burns, Tans Minimally

Type III – Sometimes Burns, Gradually Tans

Type IV – Rarely Burns, Tans Easily

Type V – Very Rarely Burns, Tans Very Easily

Type VI – Never Burns, Deeply Pigmented

SKIN ANALYSIS

Skin Type

Normal

Dry

Oily

Combination

Sensitive

Hydration Level

Poor

Fair

Good

Excellent

Elasticity

Poor

Fair

Good

Excellent

Skin Laxity

Mild

Moderate

Severe

Pigmentation

None

Mild

Moderate

Severe

Congestion

None

Mild

Moderate

Severe

Acne Grade

None

Mild

Moderate

Severe

Rosacea

None

Mild

Moderate

Severe

Scarring

None

Mild

Moderate

Severe

Texture

Smooth

Uneven

Rough

FACIAL ASSESSMENT

Forehead

Eyes

Cheeks

Nose

Jawline

Neck

Décolletage

CONTRAINDICATIONS CHECK

Contraindications

Pregnancy

Breastfeeding

Active Infection

Open Wounds

Active Herpes Simplex

Recent Surgery

Recent Injectables

Recent Laser Treatment

Recent Chemical Peel

Recent Skin Needling

Accutane Use

Allergies

Autoimmune Disease

Cancer

Other

If Other, please specify

TREATMENT SUITABILITY

Suitable Treatments

LPG Endermologie

Ultraformer MPT

Cold Plasma

Fibroblast Plasma

Enzyme Peel

TeslaChair

TeslaFormer

BMS Facial Massage

Infrared Sauna

Comments

TREATMENT PLAN

Recommended Treatment

Number of Sessions Recommended

Treatment Frequency

Expected Timeframe

Combination Treatments Recommended

HOME CARE RECOMMENDATIONS

Cleanser

Serum

Moisturiser

SPF Recommendation

Additional Recommendations

PHOTOGRAPHIC RECORD

Photographic Record

Before Photos Taken

Left Profile

Right Profile

Front View

Neck Photos

Follow-Up Photos Required

PRACTITIONER NOTES

Practitioner Notes

SIGNATURES

Client Signature

Date

Practitioner Signature

Date

Contact Info

Level 1/42 East Concourse, Beaumaris, Vic 3193
Phone: 0448 892 914
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