Aesthetic Treatment Record Form
Record client details, treatment information, relevant history, outcomes, and follow-up for aesthetic treatments.
Client and Appointment Details
Client Full Name
*
First Name
Middle Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Status
*
First Visit
Returning Client
Preferred Appointment Date and Time
*
Treatment Plan and Procedure Details
Treatment Type / Procedure
*
Please Select
Botulinum Toxin
Dermal Filler
Chemical Peel
Microneedling
Laser Treatment
Skin Booster
Facial Treatment
Body Contouring
Other
Treatment Area(s)
*
Forehead
Glabella
Crow's Feet
Cheeks
Lips
Jawline
Neck
Décolletage
Under Eyes
Hands
Full Face
Body
Other
Session Number
Treatment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Treatment Duration
Hour Minutes
AM
PM
AM/PM Option
Product / Device Used
Treatment Status
*
Please Select
Consultation Only
Treatment Performed
Follow-Up Visit
Deferred
Other
Client History and Suitability
Current skin concerns
Acne
Dryness
Oily skin
Sensitivity
Hyperpigmentation
Rosacea
Fine lines
Scarring
Uneven texture
Other
Known allergies or sensitivities
Fragrance
Latex
Adhesives
Topical anesthetics
AHA/BHA products
Retinoids
Preservatives
None known
Other
Current skincare products or topical treatments
Current medications or supplements that may affect treatment
Previous aesthetic procedures
Facial treatments
Chemical peels
Microneedling
Laser treatment
Injectables
Dermaplaning
Microdermabrasion
Thread lifting
None
Other
Contraindications or special considerations
Outcome, Aftercare, and Follow-Up
Immediate Result Assessment
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Client Satisfaction
*
1
2
3
4
5
Aftercare Instructions Provided
*
Next Recommended Follow-Up
Practitioner Follow-Up Notes
Submit
Should be Empty: