Client Profile & Skin Consultation

1

Client Information

Personal and contact details

First Name *

Last Name *

Street Address, City, State, ZIP

Phone Number *

Email Address *

2

Skin History

Past professional treatments and baseline classification

1. Have you ever had a professional facial treatment before?

No Yes

When and what type of treatments have you received?

2. Which best describes your skin type? (Select the closest match)

Type I — Always burns easily, never tans Fair skin, frequently freckled, very sensitive to sun exposure

Type II — Burns moderately, tans gradually Light skin, burns initially but develops slight tan with care

Type III — Rarely burns, deep tan Medium complexion, burns mildly occasionally, tans easily

Type IV — Seldom burns, always tans well Olive or Mediterranean tone, tans rapidly with minimal burn risk

Type V / VI — Rarely burns, deeply pigmented Deep/dark complexion, burns very rarely, high melanin content

3. Do you have special skin problems or concerns on your face or body?

No Yes

Please specify:

4. Do you use Retin-A®, Renova, Adapalene, Hydroxy Acids, Retinol/Vitamin A, or acne medications?

No Yes

Please specify product name & frequency:

3

Current Skincare Routine

List brand and product name where known (leave blank if not used)

Cleanser

Toner

Scrubs / Exfoliator

Serums / Actives

Day Moisturizer

Night Moisturizer

Sunscreen (SPF)

Eye Product

Face Mask

Retinol / Prescription

4

Skin Assessment & Goals

Reactions, hair removal, targeted focus areas, and objectives

Do you bruise easily?

No Yes

Past bad reaction to a product?

No Yes

What product was it, and what occurred to your skin?

Hair removal methods in the past 6 weeks (Select all that apply)

Hereditary Background

Any injections or dermal fillers?

No Yes

Please specify type and date of injection:

What are your primary skin goals?

5

General Health History

Contraindication screening to ensure your total treatment safety

Do you smoke or use tobacco?

No Yes

Sensitive to alcohol-based products?

No Yes

Known Allergies / Sensitivities (Select all that apply)

Asthma, hay fever, or airway disease?

No Yes

Currently taking medications?

No Yes

Which medications are you currently taking?

Are any medications anticoagulants (blood thinners)?

No Yes

Any photosensitizing drugs or supplements?

No Yes

Metal implants / screws / pins?

No Yes

Do you use a pacemaker?

No Yes

Braces or dental implants?

No Yes

Currently have a cold, cough, flu, or fever?

No Yes

Other health condition not listed?

Anything else your skincare practitioner should know?

6

Female Clients Section

Hormonal and pregnancy factors that impact skin permeability and treatment suitability

Taking oral contraceptives?

No Yes

Please specify brand/type:

Pregnant or trying to become pregnant?

No Yes

Are you currently lactating / breastfeeding?

No Yes

Any menopause-related concerns?

No Yes

Please specify:

7

Communication, Consent & Liability Waiver

Review agreement terms, provide consent, and sign below

May we contact you via text regarding appointments?

Yes No

Photo / Video Media Consent

Yes, I consent No, I decline

Photo/video permission allows Casa Piel Esthetics to document treatments for educational or portfolio purposes on social media and our website. Your comfort and privacy always remain our highest priority.

Treatment Disclosure & Liability Release

I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.

I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary, and I release this institution and/or skin care professional Carmen Beatriz Parra from any liability and assume full responsibility thereof.

Client Printed Full Name *

Date Signed *

Client Digital Signature *

Sign Here

Adopts your typed full legal name above as your binding digital mark.

Client Information

Skin History

Current Skincare Routine

Skin Assessment & Goals

General Health History

Female Clients Section

Communication, Consent & Liability Waiver

Profile Received