BEAUTÉLANIN™  •  FULL-SPECTRUM SKIN ANALYSIS™

Intake & Observation Form

MélanoScan™ + MélanoMatrix-D™ Assessment  •  Powered by NoirScience™

1

Client Information

English
Kreyòl Ayisyen
Français
2

Your Skin Story

What concerns brought you here today? Check all that apply

3

Skin History

Have you ever experienced: Check all that apply

4

Current Skin Routine

How often do you exfoliate?

5

Lifestyle & Environmental Factors

Current stress level

Do your skin concerns worsen during: Check all that apply

6

Skin Behavior Assessment

How does your skin typically respond to sun exposure?

How does your skin respond after a breakout or irritation?

How does your skin feel after cleansing?

7

Cultural & Personal Considerations

Do you wear protective hairstyles, head coverings, wraps, wigs, or extensions?

8

Practitioner Observation

PRACTITIONER USE ONLY

Complete during or immediately following the MélanoMatrix-D™ assessment session.

M
Melanin Density Distribution, concentration, tone
R
Reactivity Inflammatory response, sensitivity
B
Barrier Behavior Resilience, hydration, TEWL risk
U
UV Legacy Environmental exposure, adaptation
P
Pigment Memory PIH patterns, persistence, mapping
9

MélanoScan™ Imaging Notes

PRACTITIONER USE ONLY

Record AI imaging observations and areas of focus from the MélanoScan™ session.

10

Treatment Planning

PRACTITIONER USE ONLY

11

Client Acknowledgment

I understand that the Beautélanin™ Full-Spectrum Skin Analysis™ is an educational skin observation and assessment service designed to support skin understanding, treatment planning, and client education.

I understand that this service does not diagnose, treat, or replace medical care and that I should consult a licensed medical provider regarding any medical concerns.

Your information is kept confidential and used solely to support your skin assessment and treatment planning. It will not be shared or sold.

✦

Thank you.

Your intake form has been received. We look forward to your session and to beginning the conversation about your skin.

"You Were Never the Flaw."

Skin is not simply observed. It is understood.

Rooted in Haitian Heritage  •  Guided by Melanin-Conscious Science  •  The Skin That Remembers™