DuVall's School of Cosmetology

Microdermabrasion Assessment


First Name:

Last Name:

Email Address:

Date:

 

CLIENT ANSWER QUESTIONS 1-5

1. Have you had any cosmetic surgeries, laser resurfacing, chemical peels, or dermabrasion?

If yes, when?

2. Have you had any recent injectables, fillers, or botox?

If yes, when?

3. Do you use Retin-A, other vitamin A products, or other medications that exfoliate or thin the skin?

4. Are you currently on any photosensitizing medications?

 

STUDENT FILL OUT THE PORTION BELOW

Skin Type and Aging:

___ Fitzpatrick I

___ Fitzpatrick II

___ Fitzpatrick III

___ Fitzpatrick IV

___Fitzpatrick V

___Fitzpatrick VI

___ Rubin I

___ Rubin II

___ Rubin III

 

Skin Conditions:

___ Telangiectasias

Improved since last treatment? __Yes __No

___ Wrinkles

Improved since last treatment? __Yes __No

___ Scarring

Improved since last treatment? __Yes __No

___ Rough Texture or Solar Damage

Improved since last treatment? __Yes __No

___ Hyperpigmentation

Improved since last treatment? __Yes __No

___ Acne

Improved since last treatment? __Yes __No

 

Leave this empty:

Signature arrow


Signature Certificate
Document name: Microdermabrasion Assessment
lock iconUnique Document ID: f2910c3c48e444b8bffa1a76d01250920dd7e024
Timestamp Audit
June 16, 2021 11:37 pm CDTMicrodermabrasion Assessment Uploaded by DuVall Adminitrative Staff - [email protected] IP 47.24.68.104