Complete the form below and we will create your online profile with your prescription to the products. PATIENT CONSULTATION RECORD Step 1 Name & Surname Email Address Date of Birth Phone Number Patient History Ethnic Origin Medical Conditions Allergies Describe your skin Dry /Oily /Combination /Tone even or uneven/ Hyperpigmentation/ Smooth/ rough Scars/ Dull What products do / have you used List of cosmetic procedures What is your skin concern? History of Keloidi A keloid scar is benign and not contagious, but sometimes accompanied by severe itchiness, pain, and changes in texture. In severe cases, it can affect movement of skin. Rosacea Eczema Psoriasis Hyperpigmentation Acne Vitiligo Melasma Skin Description 1. Colour 2. Oiliness 3. Thickness 4. Laxity 5. Fragility Snap Testi ‘Pinch’ the apples of your cheeks to feel how much collagen your skin has by seeing if there are fine lines on the surface of the skin when you pinch it. Definition healthy skin Fitzpatrick Skin Typing Test - EYE COLOUR Light Blue, Grey or Green Blue, Grey or Green Blue Dark Brown Brownish Black Fitzpatrick Skin Typing Test- What is the natural color of your hair? Sandy Red Blonde Chestnut/Dark Blond Dark Brown Black Fitzpatrick Skin Typing Test - What is the color of your skin (non exposed areas)? Reddish Very Pale Pale with Beige Tint Light Brown Dark Brown Fitzpatrick Skin Typing Test - Do you have freckles on unexposed areas? Many Several Few Incidental None What happens when you stay in the sun too long? Painful redness, blistering, peeling Blistering followed by peeling Burns sometimes followed by peeling Rare Burns Never had Burns Tanning Habits- When did you last expose your body to sun (or artificial sunlamp)? More than 3 months ago 2-3 months ago 1-2 months ago Less than a month ago Less than 2 weeks ago What do you want to achieve by using the products? Have you use Obagi products before Yes No Are you pregnant? Tretinoin is not recommended during pregnancy or breast feeding. Yes No Photos Patient Photo Front Face Patient Photo Left side of Face Patient Photo Right hand side of Face