Kassia Spa

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LEMBAR TEKNIS WAJAH

TANGGAL:___________________________________________________
1. DATA PRIBADI
Nama dan marga:___________________________________________________________________________
Tanggal lahir:_____________________ Umur:______ # Anak:_____ EPS:______________________
Alamat:_________________________________________________ E-mail:_________________________
Pekerjaan:________________________________ Telepon:____________________________________

2. ALASAN UNTUK KONSULTASI

______________________________________________________________________________________________
______________________________________________________________________________________________

3. DATA KLINIS
ke. PENYAKIT KELUARGA
Diabetes Asma Hipertensi Kanker Lainnya
Yang__________________________________
B. PENYAKIT PRIBADI
Penyakit yang pernah diderita :
____________________________________________________________________________
Penyakit yang Anda derita saat ini: ________________________________________________________
Obat-obatan yang Anda konsumsi:_____________________________________________________
Metode perencanaan (wanita) ___________________________________________________
Penggunaan Prostetik: Lensa Kontak Gigi Tidak ada

4. DATA ESTETIKA
ke. IMPLAN ATAU GRAFTS
Dagu Pipi Hidung Tidak ada
B. BEDAH ESTETIKA DAN PERAWATAN ESTETIKA
blepharoplasty Rhinoplasty bikektomi Tidak ada
otoplasti Pengencangan wajah septoplasti
C. PROSEDUR ESTETIKA
Aplikasi Asam Plasma Vitamin Tidak Ada
Autologous Hyaluronic Botox C
Berapa lama?_______________________________________________

5. Analisis Estetika
ke. WARNA KULIT__________________________________________________________________________
B. TIPOLOGI KULIT________________________________________________________________________
Kulit Kombinasi Kulit Normal Kulit Kering Kulit Berminyak
Kulit Sesak Nafas Kulit Lembap Kulit Terhidrasi
C. DERAJAT DEHIDRASI
Ringan Sedang Tinggi
D. KETEBALAN KULIT
Halus Sedang Halus Sedang Sedang Tebal Tebal
Dan. PATOLOGI KULIT
Eritema Telangiectasias Papul Melasma Hiperpigmentasi
Lepuh Couperosis Pustula Keriput Vaskular Bintang
Vesikel Parut Kista Mikosis Berloque Dermatitis
Angioma Millium Ephelides Scab hirsutisme
Komedo Kutil Nevus Keratosis Urtikaria
Eksim Nodul Vitiligo
F. KECENDERUNGAN JERAWAT YA TIDAK Jenis Jerawat__________________________________

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G. ALERGI TERHADAP PRODUK

Makeup Krim Pelembab Krim Bergizi Lainnya Tidak ada
Yang?____________________________________________________________________________________
Senyawa aktif spesifik: madu strawberry anggur almond Lain-lain Tidak ada
Yang?____________________________________________________________________________________
H. PROSEDUR UNTUK MELAKUKAN
_________________________________________________________________________________________
6. PENGAMATAN UMUM
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7. KOMITMEN HUKUM
SAYA _____________________________________________________________ diidentifikasi dengan kartu
kewarganegaraan N°_____________________ Saya menyatakan bahwa informasi yang diberikan di sini
adalah benar; Saya mengizinkan ahli kecantikan untuk melakukan perawatan berikut
______________________________________________________________ Saya mengetahui semua efek dan
kontraindikasinya, saya menerima rekomendasi yang disarankan dan saya membebaskan
________________________________________________________ dari semua tanggung jawab atas segala
perubahan yang mungkin terjadi karena perawatan yang akan dilakukan.

TANDA TANGAN PENGGUNA TANDA TANGAN KECANTIKAN

CC No. CC No.

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8. LAMPIRAN

TANGGAL:__________________________

PERAWATAN YANG AKAN DILAKUKAN

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PERAWATAN YANG DILAKUKAN

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PENGAMATAN_____________________________________________________________________________
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TANDA TANGAN PENGGUNA TANDA TANGAN KECANTIKAN

CC No. CC No.

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G. ALERGI TERHADAP PRODUK

Makeup Krim Pelembab Krim Bergizi Lainnya
Yang?____________________________________________________________________________________
Senyawa aktif spesifik: madu strawberry anggur almond Lain-lain
Yang?____________________________________________________________________________________
H. PROSEDUR UNTUK MELAKUKAN
_________________________________________________________________________________________
6. PENGAMATAN UMUM
__________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________________________________________________
7. KOMITMEN HUKUM
SAYA _____________________________________________________________ diidentifikasi dengan kartu
kewarganegaraan N°_____________________ Saya menyatakan bahwa informasi yang diberikan di sini
adalah benar; Saya mengizinkan ahli kecantikan untuk melakukan perawatan berikut
______________________________________________________________ Saya mengetahui semua efek dan
kontraindikasinya, saya menerima rekomendasi yang disarankan dan saya membebaskan
________________________________________________________ dari semua tanggung jawab atas segala
perubahan yang mungkin terjadi karena perawatan yang akan dilakukan.

TANDA TANGAN PENGGUNA TANDA TANGAN KECANTIKAN

CC No. CC No.