Headings
Concerns and goals · Medical history · Medications and allergies · Previous treatments · Skin assessment · Facial assessment · Options discussed · Consent · Plan
When to use it
Use this for a first visit, before any product or device touches the skin. It records what the client wants, what is safe for them, and which options you offered, so every later treatment note has a baseline to point back to. It covers more ground than a pre-operative consultation because the client has not yet chosen a procedure.
Example
Fictional example
Concerns and goals
M.R., 42F. Says she looks tired. Bothered by under-eye hollows and forehead lines. Wants a natural result before a family wedding in 10 weeks.
Medical history
Hypothyroidism, stable. No autoimmune disease. No history of cold sores. Not pregnant or breastfeeding.
Medications and allergies
Levothyroxine 75 mcg daily. Fish oil, will stop 7 days before injections. No known drug allergies.
Previous treatments
None. No prior neurotoxin, filler or laser.
Skin assessment
Fitzpatrick II. Mild photodamage. Fine lines at the lateral canthi.
Facial assessment
Moderate tear trough hollowing. Dynamic forehead lines, mild static lines at rest. Good brow position.
Options discussed
Neurotoxin to forehead and glabella. Hyaluronic acid filler to tear troughs, staged. Risks and cost reviewed.
Consent
Written consent for neurotoxin signed today. Filler consent deferred.
Plan
Neurotoxin in 1 week. Reassess tear troughs at the 2-week check.