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
Get started with PocperThis 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.
Full name:
Date of birth:
Gender:
Female
Male
Non-binary / other
Prefer not to say
Occupation:
Contact phone / email:
Emergency contact (name / relationship / phone):
Current skincare routine — describe morning and evening:
Products currently used — select all that apply:
Cleanser
Toner
Serum
Moisturizer
SPF / sunscreen
Retinoid (retinol / tretinoin)
Vitamin C
Acids (AHA / BHA / glycolic / salicylic)
Salon / spa facials — frequency:
Never
Occasionally (1–2× per year)
Quarterly
Monthly
Weekly or more
Previous in-clinic treatments — specify type and date:
Sun exposure:
Minimal — mostly indoors
Moderate
Heavy — frequent outdoor recreation
Occupational outdoor exposure
SPF use:
Daily
Sometimes
Rarely
Never
Smoking:
Never smoker
Former smoker
Current smoker
Vape / e-cigarette user
Alcohol:
None
Occasional / social
Regular (1–3 drinks per week)
Frequent (4+ drinks per week)
Average sleep (hours per night):
Stress level (0–10):
Diet notes — typical eating habits, hydration, supplements:
Current medical conditions — please list any:
Chronic skin conditions — select all that apply:
Rosacea
Acne
Eczema / atopic dermatitis
Psoriasis
Vitiligo
Melasma
Keloid scarring tendency
Cold sores / herpes simplex
Currently pregnant or breastfeeding
Recent isotretinoin use (last 12 months)
If yes, date of last isotretinoin dose:
Taking immunosuppressants
Taking anticoagulants / blood thinners
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:
Past botulinum toxin / dermal fillers / laser / surgery — date, area, brand, results, complications:
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
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:
What does success look like to you?
Readiness for downtime — how much downtime can you tolerate?
None acceptable
1–3 days
1 week
2 weeks
Budget bracket:
I agree to clinical photography for my medical record
I agree to before-and-after photos for my own personal review
I agree to portfolio use with my face anonymized
Signed photo consent on file
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:
The information I have provided is accurate to the best of my knowledge
I understand recommendations are clinical opinions, not guaranteed outcomes
I agree to attend a follow-up consultation if I decide to finalize a treatment plan later
Thank you for completing this consultation. Your provider will review the assessment and discuss the next steps with you before any treatment is scheduled.
The Aesthetic Consultation & Skin Assessment template is a ready-to-use form from Pocper's Aesthetic / Dermatology Clinic pack. Customize the fields to match your workflow, then share a link so clients can complete it and upload documents in real time.