Aesthetic Consultation & Skin Assessment
This consultation gathers your skincare history, medical background, lifestyle, and aesthetic goals so the provider can offer realistic recommendations tailored to your skin. All recommendations are clinical opinions; no treatment is performed today.
Emergency contact (name / relationship / phone):
Current medical conditions — please list any:
Chronic skin conditions — select all that apply:
If yes, date of last isotretinoin dose:
If yes, name of anticoagulant and reason for use:
Other current medications — including OTC and supplements:
Allergies — drugs, latex, lidocaine, hyaluronic acid, topicals, metals, iodine, foods:
Cosmetic Procedure History
Past botulinum toxin / dermal fillers / laser / surgery — date, area, brand, results, complications:
Texture: [Provider documents skin texture observed during in-clinic assessment]
Pigmentation: [Provider documents pigmentation findings (even tone / sun spots / melasma / PIH / freckles)]
Lines & wrinkles: [Provider catalogues named line locations observed (forehead / glabellar / crow's feet / nasolabial / marionette / smoker's)]
Vasculature: [Provider documents vascular findings (telangiectasia / rosacea flushing / spider veins)]
Acne: [Provider grades acne sub-classification (comedonal / inflammatory / cystic / acne scarring)]
Pores: [Provider grades pore size (minimal / moderate / enlarged)]
Elasticity / laxity: [Provider grades skin laxity via palpation/inspection (firm / mild / moderate / advanced)]
Hydration: [Provider documents hydration assessment (well-hydrated / dehydrated)]
What bothers you most about your skin? In your own words:
Priority ranking — list your top 3 concerns from most to least important:
Recommended Treatment Pathway
Provider's clinical opinion (recommendations are clinical opinions, not guarantees of outcome):
Recommended treatments — up to 4 entries:
Treatment 1 — name: / indication: / estimated cost:
Treatment 2 — name: / indication: / estimated cost:
Treatment 3 — name: / indication: / estimated cost:
Treatment 4 — name: / indication: / estimated cost:
Thank you for completing this consultation. Your provider will review the assessment and discuss the next steps with you before any treatment is scheduled.