Chemical Peel Consultation Form

(Reading)

First Name *

Last Name *

Phone *

Email *

Date of birth *

Address

Street Address *

City *

State *

Postal code *

Lifestyle

Occupation? *

Do you smoke? *

Yes

No

On a scale of 1 (low) to 10 (high) how would you rate your stress levels? *

How often do you exercise? *

Daily Water Intake:- *

Main Concern/ Reason For Visit *

Are you taking any medication? *

Yes

No

Other Clinic Treatments *

Fitzpatrick Skin Type

Fill using above image *

Eye Colour
Natural Hair Colour
Colour of Exposed Skin
Freckles on sun exposed areas
What happened when you stay in sun too long?
To what degree do you turn brown
Do you turn brown several hours after sun exposure
How does your face Respond to the sun
Last use of sunbed or self treated to the sun?
Total Score
FITZPATRICK SKIN TYPE

What is your ethnic background? *

Skin Type *

Dry / Dehydrated

Combination

Oily / acne prone

Ageing - Glogau Scale *

I - Mild : little to no wrinkles

II - Moderate: Wrinkles visible in motion only

III - Advanced: Wrinkles visible a rest

IV - Severe: Mostly Wrinkled Skin

none of the above

Pls select the below *

Mild

Moderate

Severe

Acne *

0 - clear: no acne present

I - Mild: small comedones

II - Moderate : papules and pustules

III - Moderately Severe : numerous papules and pustules, inflamed nodules

IV - Severe: many large, painful nodules and pustules

Senstivity *

Sensitised

Couperose

Rosacea

Acne Rosacea

Select senstivity level *

BODY SKIN ANANLYSIS

Clients concern

Other Area of concern

Other Concerns

Other

Skin Kits

Cleansing solutions

Moisturising solutions

Anti blemish solutions

Pigmenting Control Solutions

Sensitive Solutions

Peeling Solutions

Photoprotection Solutions

Antiaging Solutions

Antiaging brightening Solutions

Antiaging Firming Solutions

Antiaging Anti-Wrinkle Solutions

Haircare Solutions

Bodycare Solutions

Client Signature

I give consent for my photos to be used for marketing/ advertising purposes *

Yes

No

I confirm that SHAPINS Clinic will not be responsible for any liability and I declare that I have read all the above details provided from the clients.

Signature *

Clear

Our aim to provide incredible results in affordable prices.

Additional Comment *

Privacy Policy | Terms of Service