SKIN HEALTH CONSULATION 

How is your skin?
Rate your skin on a scale from 1-51 – Compromised (Severely damaged, inflamed, or problematic skin)2 – Stressed (Visible concerns like acne, redness, dryness, or uneven texture)3 – Balanced (Generally healthy with some minor concerns)4 – Radiant (Glowing, smooth, and well-maintained)5 – Luminous (Flawless, youthful, and exceptionally healthy) 

When looking at my face in the mirror, I believe I look younger, the same as, or older than my true age: Answer on a scale from 1 to 51 - I look significantly older than my age2 - I look somewhat older than my age3 - I look about my age4 - I look somewhat younger than my age5 - I look significantly younger than my age 

I am concerned with the unevenness of my skin tone:
Answer on a scale from 1 to 51 - Not concerned at all2 - Slightly concerned3 - Moderately concerned4 - Very concerned5 - Extremely concerned 

My main skincare concerns are:  

What other services would you like to see us offer:  

The facial diagram below lists 9 areas on the face and declotte. If any of these areas are of concern, please check the box next to the corresponding areas.

AREAS OF CONCERN

Additional Comments:  

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Document name: Test Face Form

Unique Document ID: 6c4a9f65239124918e35da0813fc43a09f51d9b9

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Timestamp	Audit
February 5, 2025 11:48 am PDT	Test Face Form Uploaded by scott smith - scottsm8@gmail.com IP 67.168.123.88

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https://www.skinlogicmedspa.com/

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