CEMO LASER CLINIC SKIN ASSESSMENT FORM

First name

Last name

Email

Phone

Skin Assessment

What is your primary skin concern? (Select all that apply)

Have you had professional skin treatments before?

Yes, Regularly

Yes, But only once or twice

No, This is my first time

How would you describe your current skincare routine?

Minimal (cleanser & moisturizer)

Basic (cleanser, moisturizer, SPF)

Advanced (includes serums, exfoliation, masks)

Professional (prescribed treatments & in-clinic procedures)

What result are you hoping to achieve from your treatment?

Treatment Action

How soon are you looking to start your skin treatment?

As soon as possible

Within the next month

Next Year

Just exploring my options

Do you have any of the following conditions? (Select all that apply)

Have you used any prescription skincare (e.g., Retinol, Accutane) in the past 6 months?

Yes, currently using

Yes, but I stopped recently

No

Thank you for completing your skin assessment! Our skincare experts will review your responses and recommend a personalized treatment plan. Book your exclusive consultation now to take the next step toward your best skin!