Mesoestetic – Official UK distributors for Mesoestetic products in the UK

Participant Info
Date of registration
First Name
Last Name
Address
City
County
Post Code
Phone	Your primary contact number
Mobile
Email
Date of Birth
Lifestyle
Occupation
Stress Levels
Do you smoke?
Do you exercise?
If yes, how often?
Daily water intake
Recent sun / UV exposure / holidays planned:
Main Concerns / Reason for visit:
Health
Contra Indications	Contra Indications Active Skin Cancer Active Cancer Keloid Scarring Pregnancy/Lactating other: Additional Information
Contra Indications Notes
Precautions	Precautions Auto Immune Disorders Kidney Disease Blood Disorders (HIV/Hepatits) Allergies Cold Sores Eczema/Psoriasis/Dermatitis Burns/Skin Graft Tattoos/Moles/Warts Gluten Intolerance Lactose Intolerance Recent Scar Tissue Asthma Taking Steroids? Taking Blood Thinning Medications? Taking antibiotics? Taking Natural Remedies (e.g. St Johns Wort)? Taking Contraception/HRT? Taking Roaccutane? other:
Precautions Notes
Are you currently using...	Are you currently using... Retinol / Retin A AHA’s BHA’s Hydroquinone Cleanser Toning Lotion Serum Eye Cream Moisturiser SPF Treatment Cream/Mask other:
Currently using notes
Have you had the following treatments?	Have you had the following treatments? Injectable Treatments Surgery Laser/IPL Chemical Peels Hair Removal Self-Tan Other Clinic Treatments other:
Treatments notes
If so, please state when:
Eye Colour
Eye Colour Score Light blue, grey, green=0 Blue, grey, green=1 Blue=2 Dark Brown=3 Brownish Black=4
Natural Hair Colour
Hair Colour Score Sandy Red=0 Blond=1 Chestnut, Dark Blond=2 Dark Brown=3 Black=4
Colour of exposed skin
Skin colour total Reddish=0 Very Pale=1 Pale with Beige Tint=2 Light Brown=3 Brown, Dark=4
Freckles on sun exposed areas
Freckles on sun exposed areas total (Many=0; Several=1; Few=2; Incidental=3; None=4)
What happened when you stay in the sun too long?
Sun effects total (Painful, Redness, Blistering, Peeling=0; Blistering followed by peeling=1; Burns, sometimes followed by peeling=2; Rare Burns=3; Never Burns=4)
To what degree do you turn brown?
Tan Total (Hardly or Not at all=0; Light Colour Tan=1; Reasonable Tan=2; Tan Very Easily=3; Turn Dark Brown Quickly=4)
Do you turn brown several hours after sun exposure
Total (Never=0; Seldom-1; Sometimes=2; Often=3; Always=4)
How does your face respond to the sun?
Face response total (Very sensitive=0; Sensitive=1; Normal=2; Very Resistant=3; Never had a problem=4)
Last use of sunbed or self-tanning creams
Sunbed/Self-Tan Total (More than 3 months ago =0; Two to three months ago=1; One to two months ago=2; Less than 1 month ago=3; Less than 2 weeks ago=4)
Do you expose the area to be treated to the sun?
Exposure total (Never Exposed=0; Hardly Ever=1; Sometimes=2; Often=3; Always=4)
Fitzpatrick Score
FITZPATRICK SKIN TYPE ((0-7 = I, 8-16 = II, 17-25 = III, 26-30 = IV, Over 30 V-VI)
Ethnic background
What is your ethnic background?
Skin Analysis
Ageing	Ageing Dehydration Lines & Wrinkles Loss of Elasticity Texture
Acne	Acne Large Open Pores Blackheads Whiteheads Papules / Pustules Nodules / Cysts
Pigmentation	Pigmentation Uneven Skin Tone Sun Damage Hormonal PIH
Sensitive	Sensitive Rosacea Sensitized Redness
Skin Scanning
Wrinkle Assessment	Wrinkle Assessment Mild Average Moderate Severe
Elastosis Assessment	Elastosis Assessment Mild Average Moderate Severe
Photo Damage	Photo Damage Mild Average Moderate Severe
Pigment damage triggered from	Pigment damage triggered from Sun (UVA UVB HEV IR) Tanning Booth Surgery Medications
Acne Grade
Lesions Identified
Skin Scanned
Pictures Taken
Observations
Body	Body Double Chin Cellulite Arms Stubborn Fat Breasts Draining Abdomen & Flanks Lipolytic Buttocks Firming Legs Lifting Intimate
My Homecare Prescription
Programme	Programme age management kit de-pigmentation kit acne management kit sensitive skin kit
Depigmenting solutions	Depigmenting solutions melan tran3x concentrate melan tran3x gel cream cosmelan 2 dermamelan maintenance cream dermamelan intimate gel cream
Antiaging Brightening Solutions	Antiaging Brightening Solutions Brightening Concentrate Brightening cream Brightening eye contour Brightening complex plus
Photoprotection Solutions	Photoprotection Solutions mineral matt antiaging SPF50+ light water antiaging veil SPF50+ melan 130+ pigment control repairing stick SPF100+ facial sun mist SPF50+ body sun mist SPF30
Anti-Blemish Solutions	Anti-Blemish Solutions acne one imperfection control pure renewing mask
Antiaging Firming Solutions	Antiaging Firming Solutions Firming Concentrate Firming Cream Firming Eye Contour Firming Elixir
Cleansing Solutions	Cleansing Solutions hydracream fusion brightening foam purifying mousse hydratonic mist micellar bi-phasic
Bodycare Solutions	Bodycare Solutions Intensive Mist Celluxpert Firm Up Essential Cream
Antiaging Antiwrinkle Solutions	Antiaging Antiwrinkle Solutions Anti-wrinkle concentrate Anti-wrinkle cream Anti-wrinkle night cream Anti-wrinkle eye contour Anti-wrinkle lip and contour
Peeling Solutions	Peeling Solutions ultimate micropeel resurfacing peel booster brightening peel booster glycorepair glycolic + E + F ampoules
Grascontrol Supplements	Grascontrol Supplements artichoke carnitine
My Homecare Prescription continued
Moisturising Solutions	Moisturising Solutions ha densimatrix hydra vital factor k hydra vital mask crystal fiber mask
Haircare Solutions	Haircare Solutions tricology intensive lotion tricology hair loss shampoo
Sensitive Skin Solutions	Sensitive Skin Solutions fast skin repair melan recovery anti stress mask couperend cream Skin balance
Antiaging Global Solutions	Antiaging Global Solutions aox ferulic anti-ageing flash ampoules proteoglycans ampoules melatonin ampoules pollution defense ampoules
My Homecare Prescription Notes
-
My Treatment Programme
Please tick all that apply:
Mesopeels (M=Medical)
Age Management	Age Management 1-3 Glycolic 20% 1-3 Glycolic 35% 1-3 Glycolic 50% 1-3 Glycolic 70% M 1-6 Mesoeclat 1-2 phen TCA M
Dehydrated, Dull, Sensitive	Dehydrated, Dull, Sensitive 1-4 lactic 30% 1-4 lactic 40% 1-4 lactic 50% M
Oily Acne Prone	Oily Acne Prone 1-6 salicyclic 10% 1-4 salicyclic 20% 1-4 salicyclic 30% M 1-6 Azelan 1-4 Acnelan M
Pigmentation	Pigmentation 1-6 Melanostop 1-6 Cosmelan 1-6 Dermamelan M 1-3 Melanoplus M
Universal Concerns	Universal Concerns 1-6 Mandelic 30% 1-6 Mandelic 40% 1-4 Mandelic 50% M 1-6 Modified Jessner 1-3 TCA Soft 15% 1-3 TCA 35% M
Eyes	Eyes 1-6 Global Eyecon 1-6 Periocular M
Other Treatments (M=Medical)
Other treatments	Other treatments 1-6 m.pen PRO Micro-needling 1-6 mesoprof ampoules 1-6 mesotherapy 1-6 Mesohyal ampoules 1-6 mesofiller M 1-6 1-4 Carboxy Therapy M
Facials
Select facial treatments	Select facial treatments 1-6 m.flash facial 1-6 Age Element
Radio Frequency / LED
Select...	Select... 1-6 GENESIS Face
Body Treatments
Select Body Treatments	Select Body Treatments 1-6 Genesis Body 1-6 Bodyshock Solutions 1-6 1-6 Dermamelan Intimate
Suggested Programme
Programme
My Personal Prepping Programme
Use for minimum 2 weeks prior to treatment
Cleanser
Prepping Booster
SPF
Other(s)
AVOID PRE-TREATMENT:	Exfoliating agents (scrubs) - 48 hrs prior AHA's, BHA's, Retinol, Self-Tans (unless prescribed) - Up to 14 day's prior Waxing, Hair removal or bleaching - 14 day's prior UV or Sun Exposure - 14 day's prior Notify if cold sores present within - 14 day's prior
AVOID POST TREATMENT:	Non Mineral Make-Up - 48 hour's after AHA's, BHA's, Retinol - Up to 14 day's after (30 days for cosmelan/dermamelan) Exercise, heat treatments - Up to 14 day's after Waxing, Hair removal or bleaching - 14 day's after (3 months for cosmelan/dermamelan) Sunbeds, Swimming, Sauna's, Self-Tan - 14 day's after (Never sunbeds)
Consent
Treatment
I agree that:	I agree that: I have completed the client information form accurately I have been candid in revealing any condition that could prohibit this treatment such as pregnancy/ medications/ recent surgery/ medical or clinical treatments/ recent use of Retin A or use of Roaccutane within the past 6 months I understand that there are no guaranteed results from this treatment. There are many variables such as age/ sun damage/ on-going sun exposure/ smoking/ excessive alcohol intake/ climate/ diet and water intake/ skin thickness and sensitivity. I understand that I may or may not peel and each case is different Regardless of precautions taken I acknowledge the possibility of an adverse reaction and accept sole responsibility for any medical care that may become necessary. I will contact the treatment provider if a reaction was to occur I will not scratch/ pick/ pull/ abrase the treated skin I understand that direct exposure to the sun and use of sun bed is prohibited during the treatment and recovery time of the skin and that the use of a mesoestetic/ clinic recommended sun protection is mandatory when subject to UVA/ UVB/ HEV or IR/ even when its cloudy and in the winter. Applied every 2 hours I understand that for maximum results the recommended homecare routine must be followed. I understand that If I alter the routine or use products not provided by my treatment provider the results could be altered or inhibited. I also understand it may take several treatments to obtain the desired results I understand that the following side effects may occur: 1. Discomfort 2. Redness and inflammation 3. Hypo pigmentation 4. Hyper pigmentation 5. Skin Peeling or flaking for up to 14 days 6. Infection 7. Scarring 8. Acne Breakouts I agree to the treatment provider (or assistant) to take before and after images before and after treatments I understand the goals of the treatment as well as the limitations and possible complications the treatment provider has provided me with pre and post treatment Instructions the treatment provider has provided the information and has answered all my questions concerning this procedure and I clearly understand the above information I understand that the practice of medicine and surgery is not an exact science and therefore that no guarantee can be given as to the results of the treatment referred to in this document. I accept and understand that the goal of this treatment is improvement not perfection and that there is no guarantee that the anticipated results will be achieved
Cost of the treatment
Or a course of treatments at
Signature
Treatment Progress Record
Date taken
Practitioner Name
Treatment details
Pre Pictures Taken?	Pre Pictures Taken? Yes No
Products Used
Time on Skin
Treatment Number	Treatment Number 1 2 3 4 5 6 Maintenance
Post Treatment Instructions given	Post Treatment Instructions given Yes No
Post Treatment Observations / Reactions / Comments
Signatures
Client Signature
Practitioner Signature
Treatment 2
Treatment 2 Date
Treatment 2 Practitioner
Treatment 2 treatment
Treatment 2 Pre Pictures Taken?	Treatment 2 Pre Pictures Taken? Yes No
Treatment 2 - changes since last treatment (medical/health)?
Treatment 2 products used
Treatment 2 time on skin
Treatment 2 observations/reactions/comments
Treatment 2 post-treatment instructions given?	Treatment 2 post-treatment instructions given? Yes No
Treatment 2 post-pictures taken?	Treatment 2 post-pictures taken? Yes No
Treatment 2 next session date
Treatment 2 Signatures
Treatment 2 Client Signature
Treatment 2 Practitioner Signature
Treatment 3
Treatment 3 Date
Treatment 3 Practitioner
Treatment 3 treatment
Treatment 3 Pre Pictures Taken?	Treatment 3 Pre Pictures Taken? Yes No
Treatment 3 - changes since last treatment (medical/health)?
Treatment 3 products used
Treatment 3 time on skin
Treatment 3 observations/reactions/comments
Treatment 3 post-treatment instructions given?	Treatment 3 post-treatment instructions given? Yes No
Treatment 3 post-pictures taken?	Treatment 3 post-pictures taken? Yes No
Treatment 3 next session date
Treatment 3 Signatures
Treatment 3 Client Signature
Treatment 3 Practitioner Signature
Treatment 4
Treatment 4 Date
Treatment 4 Practitioner
Treatment 4 treatment
Treatment 4 Pre Pictures Taken?	Treatment 4 Pre Pictures Taken? Yes No
Treatment 4 - changes since last treatment (medical/health)?
Treatment 4 products used
Treatment 4 time on skin
Treatment 4 observations/reactions/comments
Treatment 4 post-treatment instructions given?	Treatment 4 post-treatment instructions given? Yes No
Treatment 4 post-pictures taken?	Treatment 4 post-pictures taken? Yes No
Treatment 4 next session date
Treatment 4 Signatures
Treatment 4 Client Signature
Treatment 4 Practitioner Signature
Treatment 5
Treatment 5 Date
Treatment 5 Practitioner
Treatment 5 treatment
Treatment 5 Pre Pictures Taken?	Treatment 5 Pre Pictures Taken? Yes No
Treatment 5 - changes since last treatment (medical/health)?
Treatment 5 products used
Treatment 5 time on skin
Treatment 5 observations/reactions/comments
Treatment 5 post-treatment instructions given?	Treatment 5 post-treatment instructions given? Yes No
Treatment 5 post-pictures taken?	Treatment 5 post-pictures taken? Yes No
Treatment 5 next session date
Treatment 5 Signatures
Treatment 5 Client Signature
Treatment 5 Practitioner Signature
Treatment 6
Treatment 6 Date
Treatment 6 Practitioner
Treatment 6 treatment
Treatment 6 - changes since last treatment (medical/health)?
Treatment 6 products used
Treatment 6 time on skin
Treatment 6 observations/reactions/comments
Treatment 6 post-treatment instructions given?	Treatment 6 post-treatment instructions given? Yes No
Treatment 6 post-pictures taken?	Treatment 6 post-pictures taken? Yes No
Treatment 6 next session date
Treatment 6 Signatures
Treatment 6 Client Signature
Treatment 6 Practitioner Signature
Further Treatment Notes
Please add details of further treatment

Participant Info

Lifestyle

Health

Eye Colour

Natural Hair Colour

Colour of exposed skin

Freckles on sun exposed areas

What happened when you stay in the sun too long?

To what degree do you turn brown?

Do you turn brown several hours after sun exposure

How does your face respond to the sun?

Last use of sunbed or self-tanning creams

Do you expose the area to be treated to the sun?

Fitzpatrick Score

Ethnic background

Skin Analysis

Skin Scanning

My Homecare Prescription

My Homecare Prescription continued

My Homecare Prescription Notes

My Treatment Programme

Mesopeels (M=Medical)

Other Treatments (M=Medical)

Facials

Radio Frequency / LED

Body Treatments

Suggested Programme

My Personal Prepping Programme

Consent

Treatment Progress Record

Signatures

Treatment 2

Treatment 2 Signatures

Treatment 3

Treatment 3 Signatures

Treatment 4

Treatment 4 Signatures

Treatment 5

Treatment 5 Signatures

Treatment 6

Treatment 6 Signatures

Further Treatment Notes