Client Patient Aesthetics Form

Patient Name

Email Address

Phone Number

Gender Gender Female Male

Q1: Have you had an aesthetic treatment before? Q1: Have you had an aesthetic treatment before? Yes No (go to Q4)

Q2: If yes, how many aesthetic treatments have you had in the last 2 years? Q2: If yes, how many aesthetic treatments have you had in the last 2 years? 1-3 4 or more

Q3: What types of treatments have you ever had before? Tick all that apply. Q3: What types of treatments have you ever had before? Tick all that apply. Laser/skin resurfacing Acne treatment Radiofrequency for skin tightening Ultrasound therapy for skin tightening Anti wrinkle injections Dermal filler injections Skin quality injections Body contouring Facial surgery Body Surgery

Others (please specify)

Q4: What type of skin issues are constantly bothering you? Q4: What type of skin issues are constantly bothering you? Pigmentation/blemishes Dry/tired/dull skin Pores Rough/uneven skin Pores Lines and wrinkles Saggy/lax skin Sensitive skin type Scarring Rosacea

Q5.1 Your Areas of Interest - FACE Q5.1 Your Areas of Interest - FACE Forehead shape Forehead lines Frown lines Cheek definition Nose shaping Nasolabial folds Marionette lines Jowls Chin contour Temple hollowing

Q5.2 Your Areas of Interest - EYE AREA Q5.2 Your Areas of Interest - EYE AREA Eyebrow shape Crow's feet line Eye bag Tear trough

Q5.3 Your Areas of Interest - LIPS Q5.3 Your Areas of Interest - LIPS Lip lines Downturn mouth Border/volume

Q5.4 Your Areas of Interest - SKIN Q5.4 Your Areas of Interest - SKIN Skin texture & quality Skin pigmentation, sun damage

Q5.5 Your Areas of Interest - HAIR Q5.5 Your Areas of Interest - HAIR Permanent hair removal Hair loss

Q5.6 Your Areas of Interest - NECK/BODY Q5.6 Your Areas of Interest - NECK/BODY Neck line/ageing Body contouring

Q5.7 Your Areas of Interest - OTHERS Q5.7 Your Areas of Interest - OTHERS Weight loss Facial reshaping Excessive sweating

Others (please specify)

Q6: Which three statements best reflect how you would like to look and feel after the treatment? Q6: Which three statements best reflect how you would like to look and feel after the treatment? I want to look less tired I want to look less angry I want to look less said I want to look less saggy I want to look more youthful I want to look more attractive I want to look more feminine (female) / masculine (male) I want my face to look slimmer