FACIAL COSMETOLOGY CARD

Date: ___________________________ File No: _______________________

1. PATIENT IDENTIFICATION:
Name: _________________________________ Age: _____ Sex: M ( ) F ( )
Cedula number: _______________________ Date of birth: ________________
Telephone number: _________________ E-mail: ______________________
Blood type: ______________ In case of emergency: ___________________________

Reason for inquiry: _________________________________________________________

2. MEDICAL HISTORY:
Diseases: ________________________________________________________
Antecedentes Familiares: ________________________________________________
Alergias: ______________________________________________________________
Medications: ________________________________________________________
Surgical: ___________________________________________________________
Facial Aesthetics: ______________________________________________________

 Eating Habits:
Water: Vegetables and fruits: Carbohydrates:
( ) Always ( ) Always ( ) Always ( ) Always
( ) Occasionally ( ) Occasionally ( ) Occasionally ( ) Occasionally
( ) Never ( ) Never ( ) Never ( ) Never

 Toxic Habits:
Alcohol: Tobacco: Other: ____________
( ) Always ( ) Always
( ) Occasionally ( ) Occasionally
( ) Never ( ) Never

3. AESTHETIC ANALYSIS
 Regular skin care
Skin cleansing: _______ Frequency: _________ Product: _____________________
Exfoliation: _______ Frequency: _________ Product: ____________________________
Moisturizing: _______ Frequency: ________ Product: ____________________________
Sun protection: ______ Frequency: _______ Product: __________________________

 Skin phototype

( ) I ( ) II ( ) III ( ) IV ( ) V ( ) VI ( ) VII
 Skin typology

( ) Normal ( ) Mixed ( ) Dry ( ) Oily ( ) Oily

( ) Smothered ( ) Devitalized ( ) Sensitive ( ) Sensitive
Miguel Riofrio between Bolivar and Bernardo Valdiviezo, Loja - Ecuador
0992611362
  Dehydration Level
( ) Light ( ) Medium ( ) High ( ) High

 Texture
( ) Greasy ( ) Thin ( ) Rough ( ) Smooth and fine ( ) Granular
( ) Opaque ( ) Oily ( ) Oily ( ) Shiny ( ) Oily ( ) Glossy

 Shade
( ) Yellow ( ) Pink

 Cutaneous pathologies:

( ) Expression lines ( ) Comedones ( ) Scars ( ) Scars

( ) Wrinkles: ( ) Between eyebrows ( ) Papules ( ) Keratosis
( ) Periorbicular ( ) Pustules ( ) Hyperpigmentation
( ) Nasogenian ( ) Cysts ( ) Telangiectasias ( ) Telangiectasias ( ) Peribuccal ( ) Milium ( ) Nevus ( )
( ) Erythema ( ) Cysts ( ) Couperosis
( ) Angiomas ( ) Warts ( ) Eczema ( )

 Facial Map

4. DIAGNOSIS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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5. PROTOCOL

PROCESS PRODUCT REMARKS

1.

2.

Miguel Riofrio between Bolivar and Bernardo Valdiviezo, Loja - Ecuador

0992611362
 3.

4.

5.

6.

7.

8.

6. REMARKS
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

7. RECOMMENDATIONS
______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________

*Once the form is filled out, the patient's condition upon arrival at the cosmetology booth is made known
and the process to be performed is informed.
*By signing the facial cosmetology form, the patient authorizes the professional to proceed with the
protocol.
*Photographs taken at the beginning and end of the session are attached as proof of the above.

___________________________________ __________________________________
PATIENT AUTHORIZATION SIGNATURE CTLGA. DAYANARA LUCÍA CABRERA JADÁN
Name:
C .I. :

Miguel Riofrio between Bolivar and Bernardo Valdiviezo, Loja - Ecuador

0992611362