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About Us
Products
About md:ceuticals
Homecare
Professional Use
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Shop
Training
Blog
Contact Us
Products search
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/ MD:Peel Treatments
MD:Peel Treatments
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Md:peel Intimate White
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md:peel glycolic
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md:peel mandelic
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md:peel salicylic
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md:peel pyruvic 40% lactic 10%
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md:peel azelaic 17% salicylic 20%
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md:peel Modified Jessner
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Neutralizing Solution
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md:Tranex Retipeel
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FACIAL DIAGNOSIS
Aesthetic alteration to be improved
How long have you been suffering it?
PERSONAL DATA
First name
Surname
Date of birth
Marital status
Address
Postal code
City
Telephone
Email
Nationality
Occupation
Do you take any medication?
Yes
No
(if Yes) What medication?
Diseases
Autoimmune disease
Diabetes
Active Herpes Simplex
Viral infections
Other
(If Other) Please complete
Surgical interventions (if so, please list the intervention as well date of the intervention)
Allergies
Are you pregnant?
Yes
No
(If Yes) How many months
Do You Have Children?
Yes
No
(If Yes) How many
Menopause?
Yes
No
Menstrual disorder?
Yes
No
Hormonal disorders?
Yes
No
Do you take contraceptives?
Yes
No
Prior skin sensitivity?
Yes
No
Do you take Cortisone?
Yes
No
Tretinoin ingestion (Roaccutane/Retin)?
Yes
No
TREATMENTS AND PRODUCTS BEING USED (specify last date of use):
Laser
Electrolysis
Waxing
Depilatories
Dermabrasion
Chemical peels
Exfoliating products
Recent surgery
Others
(If Other) Please stipulate
HABITS (Specify last date of use):
Alcohol use
usual
weekend
occasional
abstemious
Do you smoke
Yes
No
(If Yes) How many cigarettes per day
Sport Practice
Yes
No
(If Yes) Frequency
On a diet
Yes
No
Do you loose weight easily
Yes
No
Sun tanning
Yes
No
(If Yes) Frequency
Artificial tanning
Yes
No
(If Yes) Last exposition
How much water do you drink a day?
Daily skin care
SKIN DATA:
General appearance
Fresh
Tired
Devitalized
Aged
Grade of hydration
Normal
Dehydrated
Very dehydrated
Hyper hydrated
Sebaceous/oily secretion
Normal
Dry
Oily
Colouring
Normal
Yellowish
Reddish
Greyish
Texture
Normal
Thin
Thick
Rough
Pore
Normal
Dilated
Blocked
Brightness
Bright areas
Mat areas
Vascular/Redness
Erythrosis/eritema
Ruby point
Telangiectasia
Vascular spider
Couperosis
Angioma
Rosacea
Alterations
Scars
Keloids
Eczema
Collagen disease
Skin flaccidity/Loss of elasticity
Oval face
Chin
Cheeks
Eyelids
Others
Skin Phototype (Fitzpatrick)
I
II
III
IV
V
VI
Fitzpatrick Guide
View guide as referrence
click on guide to complete form
Skin Aging
GRADE
I
II
III
IV
Grade Guide
View guide as referrence
click on guide to complete form
PLEASE UPLOAD THE FOLLOWING PHOTOS OF YOURSELF
Front of face
Left side of face
Right side of face
Pictures of skin conditions that are problems
Send
