Client Intake + MRBUP® Record

IClient Information

Full Name *

Preferred Name

Date of Birth

Pronouns

Phone *

Email *

Address

Occupation / Work Environment

Emergency Contact

Emergency Phone

What brings you to Beautélanin® today?

What would you most like us to understand about your skin?

Is there anything you do not want performed during the service?

IIYour Skin Story

We want to understand your experience with your skin before we begin observing it.

How has your skin been behaving lately?

What changed, and when did you first notice it?

Are these changes:

New Recurrent Long-standing Seasonal Occasional Gradually changing Unsure

Do the changes recur in the same areas?

Yes No Unsure

If yes, where?

What tends to occur beforehand?

Product use Menstrual cycle Hair removal Shaving Breakouts Waxing Friction Exercise / sweat Heat Travel / climate change UV exposure Professional treatment Stress No pattern noticed Hormonal change

Other:

IIIReactivity History

How does your skin communicate discomfort? (Check all that apply)

Burning Flaking Stinging Roughness Itching Bumps Warmth Welts Redness / visible color change Rash-like response Swelling Pigment change after irritation Tightness Prolonged sensitivity Tenderness None reported

Other:

Does your skin react quickly to new products?

Frequently Sometimes Rarely Unsure

Ever reacted after a facial or treatment?

Yes No

If yes, what happened?

Did the reaction leave pigmentation afterward?

Yes No Unsure

How long to return to usual state?

IVBarrier Behavior

We do not ask whether your skin is "dry" or "oily" — we want to understand how it manages water, oil, comfort, and environmental stress.

Immediately after cleansing, your skin usually feels:

Comfortable Tight Very tight Soft Itchy Warm Stinging Rough Not noticed

During the day, do you experience:

Visible flaking Tightness Surface roughness Oil shortly after cleansing Oil + tightness simultaneously Makeup clinging / separating Products stinging unexpectedly Frequent need to reapply moisturizer None of these

Does your skin tolerate weather changes well?

Usually Sometimes Rarely Unsure

Changes between indoor / outdoor environments?

Yes No Unsure

Describe:

VSebum Behavior

Where do you notice oil appearing most?

Forehead Hairline Nose Entire face Chin Very little visible oil Cheeks Pattern varies

When does oil usually appear?

Soon after cleansing By midday Toward evening Heat / humidity Hormonal changes Pattern varies

Oiliness while simultaneously feeling tight / dehydrated?

Yes No Unsure

Aggressive cleansing / exfoliation increases oil production?

Yes No Unsure

VIPigment History

Pigment is not treated as a defect at Beautélanin®. We want to understand when, where, and why pigment changes occur.

Does your skin tend to leave a darker mark after:

Breakouts Peels Cuts / scratches Burns Insect bites Rashes Waxing Friction / pressure Shaving Other inflammation Picking Not usually Extractions

How long do marks typically remain?

Days Weeks Several months Longer than 6 months More than 1 year Unsure

Pigment returning in previously affected areas?

Yes No Unsure

Do certain areas retain pigment more readily?

Yes No

Where?

Have you used products to lighten, bleach, fade, brighten, or suppress pigmentation?

Yes No Unsure

If yes, please list what you remember:

What happened while using them?

What happened after you stopped?

VIIUV Legacy & Environment

We do not use sunburn history to assign a racialized skin category. We consider your cumulative relationship with UV exposure.

Where did you spend most of your childhood?

What climate(s) have you lived in for extended periods?

Current typical daily UV exposure:

Minimal Intermittent Moderate Significant Varies

Do you currently use sunscreen / photoprotection?

Daily Most days Occasionally Rarely Never

Do you spend significant time near windows?

Yes No

Do you drive frequently?

Yes No

Persistent differences between more-exposed and less-exposed areas?

Yes No Unsure

Describe:

VIIICurrent Skincare Routine

AM Cleanser

PM Cleanser

AM Serum / Treatment

PM Serum / Treatment

AM Moisturizer

PM Moisturizer

Sunscreen

Other

How often do you exfoliate?

Never Occasionally Once weekly 2–3x weekly 3+ times weekly

What do you use?

Scrub Enzyme AHA BHA PHA Retinoid / retinol Exfoliating pads Brush / device

Other:

When did you last exfoliate?

IXRecent Procedures & Treatments

Within the applicable recent period, have you received:

Chemical peel Threading Microdermabrasion Extractions Dermaplaning Injectables Microneedling Cosmetic surgery Laser Tattoo / permanent makeup IPL / light Other professional treatment Waxing None

Procedure / Date

Area treated

How did your skin respond?

Did pigmentation remain afterward?

Yes No Unsure

XHealth & Safety Screening

This information helps determine whether a service should proceed, be modified, postponed, or referred.

Are you currently experiencing or being treated for:

Active skin infection Psoriasis flare Open wound Recent sunburn Active cold sore / HSV Significant irritation Significant swelling Recent allergic response Unexplained rash Eye infection Dermatitis flare Fever / contagious illness Eczema flare None

Allergies / Known sensitivities

Current medications relevant to skin or treatment

Current topical prescriptions

Current or recent retinoid use

Accutane / isotretinoin history

Never Currently using Previously used

If previously used, when discontinued?

Pregnant or breastfeeding?

Yes No Prefer not to answer

Medical history that may affect today's service?

Yes No

Please explain:

XITouch, Comfort & Client Autonomy

Your comfort matters throughout the service.

Areas comfortable having treated:

Face Scalp Hands Neck Shoulders Décolleté Arms

Areas you do not want touched:

Pressure preference:

Feather-light Light Moderate Ask during treatment

Temperature preference:

Cool Neutral Warm Ask me

Would you like the practitioner to explain each step?

Yes No Only when something changes

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Client Autonomy: You may pause, modify, or withdraw consent for any portion of the service at any time.

XIIClient Consent & Acknowledgment

I confirm that I have disclosed relevant health, medication, product, procedure, and skin-history information to the best of my knowledge. I understand that services are esthetic and educational, do not diagnose or treat medical conditions, and may be modified, deferred, or declined for safety.

I understand that outcomes cannot be guaranteed and that I may ask questions or withdraw consent before or during treatment.

Potential and Unexpected Skin Responses: I understand that individual skin responses cannot be predicted with absolute certainty. Following a facial or skin therapy treatment, temporary or unexpected responses may occur, including sensitivity, dryness, tightness, warmth, temporary erythema or visible color change, itching, irritation, swelling, increased visibility of existing congestion, comedones, papules, pustules, acne flare, or post-inflammatory pigment change.

I understand that an unexpected post-treatment response does not, by itself, establish its cause. Beautélanin® may consider treatment variables together with my baseline skin behavior, medications, current skincare, cosmetics, recent procedures, environmental exposures, friction, heat, UV exposure, and other relevant factors when evaluating the response.

I agree to report significant or unexpected changes and follow the post-treatment instructions provided.

Client Signature

Date

Practitioner Signature

Date

Consent applies to today's planned service and may be changed or withdrawn by the client at any time.

PRACPractitioner Section — MélanoMatrix-D™ Structured Observation

Observation Date

Practitioner

Baseline / Reassessment

Encounter / Visit #

Comprehensive Client Intake, Skin Observation & Treatment Planning Form

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