In2Skin
(852) 6511 6689
Name:
DOB:
Phone:
Email:
Preferred Contact: TextEmailCall
Emergency Contact Name & Phone:
How did you hear about us? WebsiteSocial MediaReferralGoogleWalk-inOther
Skin Conditions: AcneRosaceaEczemaCold SoresPsoriasisSensitive SkinKeloidsSkin Cancer
Health Conditions: DiabetesHigh Blood PressureHeart ConditionsEpilepsyAutoimmune DisorderThyroid IssuesPregnancyAllergiesOther
Medications: Retinoids / Retin-AAccutane (past 6 months)Blood ThinnersSteroidsHormonal TherapyAntibioticsOther
Under medical care? YesNo
Recent cosmetic procedures? YesNo
What would you like to improve? Fine Lines/WrinklesFirmnessPigmentationTextureAcneDullnessOther
Have you had professional skin treatments before? YesNo
If yes, what type & how was your experience?
What result are you hoping for from today’s treatment? Gentle refreshVisible liftMajor transformationNot sure
When do you expect to see results? ImmediatelyAfter a few sessionsI understand it takes time
How long do you expect results to last? Long-termShort boostPermanentlyNot sure
What would disappoint you about a treatment? Subtle resultsNeeding multiple sessionsDowntimeOther
Are you open to a recommended treatment plan or skincare routine? Yes, I trust your adviceMaybeNo, I prefer one-off sessions
Do you follow aftercare instructions when given? AlwaysMost of the timeI forget / not really
Are you comparing your desired results to any social media trends or filtered looks? NoA littleYes
What products do you use daily?
Wear sunscreen daily? YesNo
Water intake per day: <1L1-2L2L+
Smoke or vape? YesNo
Tanning/sunbed use? YesNo
I confirm the above information is true to the best of my knowledge.
I understand that treatment results vary and may require multiple sessions.
I will inform in2Skin Beaute of any health changes before future treatments.
I give permission to proceed with the discussed service(s).
Optional: I consent to photo documentation for progress/education
Consent to photo documentation? YesNo
Client Signature:
Date:
Summary of Concerns:
Treatment Plan:
Patch Test Needed? YesNo
Next Visit:
