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Aesthetic / Dermatology Clinic

Skin assessment and consultation, treatment plan with informed consent, session records, follow-up outcome assessments, and annual maintenance plans for aesthetic clinics, med spas, and dermatology practices

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Patient Skin & Treatment Chart


This is your standing chart with the clinic — one copy that you and your provider keep current across every visit. It is not filled in again per appointment: consultation notes, session records and follow-ups all feed back into this chart. Update it whenever your skin, medications or health status change.

Patient Identity

Full name:
Chart / patient reference number:
Date of birth:
Mobile:
Email:
Emergency contact (name / relationship / phone):
Referring physician or dermatologist, if any:
Patient since:
Primary provider:

Standing Skin Profile

Fitzpatrick skin type:
Type I — pale, always burns, never tans
Type II — fair, usually burns, tans minimally
Type III — medium, sometimes burns, tans gradually
Type IV — olive, rarely burns, tans easily
Type V — brown, very rarely burns, tans deeply
Type VI — deeply pigmented, never burns
Standing skin concerns — select all that apply:
Pigmentation — melasma, sun spots, post-inflammatory hyperpigmentation
Lines and volume loss
Laxity — jawline, neck, mid-face
Acne, congestion or enlarged pores
Redness, rosacea or visible vessels
Scarring — acne, surgical or traumatic
Dryness, sensitivity or compromised barrier
Baseline skin notes — texture, tone, sensitivity, healing tendency, keloid history:

Allergies & Current Medications

Allergies — drugs, lidocaine and other anaesthetics, latex, hyaluronic acid, topicals, metals, iodine, adhesives, foods:
Current medications and supplements — including dose and prescriber:
Isotretinoin — date of last dose (leave blank if never taken):
Anticoagulant / antiplatelet in use — name and indication:
Medication review last confirmed on:

Contraindications & Status Flags

Tick every flag that currently applies, and clear it once it no longer does.
Currently pregnant
Currently breastfeeding
Active infection, open wound or inflamed lesion in a treatment area
Recurrent cold sores — antiviral prophylaxis required before perioral work
Keloid or hypertrophic scarring tendency
Autoimmune condition or immunosuppressive therapy
Neuromuscular disorder — relevant to botulinum toxin
Permanent filler or unknown implant material previously placed
Photosensitising medication in use — laser and IPL caution
Notes on any flag above — dates, prescriber advice, clearance obtained:

Cumulative Treatment Log

One row per treatment, newest at the bottom. Record product brand and lot number for every injectable — this is the traceability record.
Date
Modality
Area
Product / brand / lot
Units / ml
Provider




































Overflow log — continue here when the table is full:

Device Settings That Worked

Keep the parameters this patient tolerated well so any provider can reproduce them safely.
Device / platform
Handpiece / tip
Settings tolerated
Reaction observed

















Adverse Reaction History

Record every unexpected reaction with its date, the treatment involved, how it was managed and how it resolved — including bruising beyond the norm, prolonged swelling, nodules, pigment change, blistering or vascular events.
Treatments or products now permanently avoided for this patient:

Photo Archive

Index the clinical photo sets held for this patient so any provider can retrieve the correct baseline for comparison.
Date
Archive / set ID
Views captured
Purpose
















Photo consent scope currently on file:
Clinical record only
Before-and-after review with the patient
Anonymised portfolio or teaching use

Current Home-Care Regimen

Morning routine — products in order of application:
Evening routine — products in order of application:
Active ingredients in use (retinoid, acids, vitamin C, hydroquinone):
Regimen last reviewed on:

Running Chart Notes

Dated entries as things change — a new medication, a pregnancy, a treatment plan agreed, a goal met, a preference to remember. Newest at the top.
Chart last updated on:
Updated by:

Keep this chart current — it is the record every provider in the clinic works from before touching your skin.
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Templates in this pack

The Aesthetic / Dermatology Clinic pack includes 7 ready-to-use templates. Each one is a structured, fully editable form you can share with clients to collect information, documents, and signatures in one place.

Frequently asked questions

What's included in the Aesthetic / Dermatology Clinic templates?
The Aesthetic / Dermatology Clinic pack contains 7 templates: Patient Skin & Treatment Chart, Aesthetic Consultation & Skin Assessment, Treatment Plan & Informed Consent, Treatment Session Record, Follow-Up & Outcome Assessment, Annual Review & Maintenance Plan, Treatment Menu & Aftercare Guide. Each is ready to use and fully editable.
Can I customize these templates?
Yes. Every Pocper template is fully editable — add or remove fields, change the wording, and adapt each form to your workflow before sharing it with clients.
How do I use the Aesthetic / Dermatology Clinic templates?
Import the pack into your Pocper workspace, open a template, tailor it to your needs, then share a link so clients can fill it out and upload documents in real time.