Skin Type QuestionnaireClient Name *Natural Eye Colour0 = Light Blue, Green, Grey 1 = Blue, Green, Grey 2 = Hazel/Brown 3 = Dark brown 4 = Brownish BlackNatural hair colour0 = Red, Sandy 1 = Blonde 2 = Light brown, Dark blonde 3 = Dark brown 4 = BlackColour of non-exposed skin0 = White 1 = Very pale 2 = Pale with beige tint 3 = Light brown 4 = Dark brown/blackDo you have freckles on exposed skin?0 = Many 1 = Several 2 = Few 3 = One or two 4 = NoneTotal Score of genetic disposition:What happens if you stay too long in the sun?0 = Painful redness, blistering, peeling 1 = Blistering followed by peeling 2 = Burns sometimes followed by peeling 3 = Rarely burns 4 = Never burnsTo what degree do you turn brown?0 = Hardly or not at all 1 = Light colour tan 2 = Reasonable tan 3 = Tan very easily 4 = Turn dark brown quicklyDo you turn brown within several hours of exposure?0 = Never 1 = Rarely 2 = Sometimes 3 = Often 4 = AlwaysHow does your face react to the sun?0 = Very sensitive 1 = Sensitive 2 = Normal 3 = Very resistant 4 = NeverTotal score of reaction to sun exposureFitzpatrick skin type:0-5= I 6-12= II 13-19= III 20-25= IV 26-31= V 32 or more= VIGDPR *Yes, I agree with the privacy policy and terms and conditions.I accept that any treatment I have taken is at my own risk. I certify that i have read and completed the above to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect, unknown because of this to which I accept full liability/responsibility I fully understand the above concent/permit and treatment/s to be carried out. The undertaken of the treatment/s has been fully explained to me. I accept full responsibility for this and or other complications which may arise or result during or following any procedure that is performed at my request.Your browser does not support e-Signature field.Submit
