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.


Appointment Deposit, Cancellation &
Rescheduling Policy

At Beautélanin™, we understand that life happens. Unexpected situations, family obligations, illness, and emergencies can arise without warning. We believe in extending grace when possible and treating our clients with the same respect we hope to receive.

To reserve your appointment time, a non-refundable deposit equal to 50% of the scheduled service is required at the time of booking. Appointments are not confirmed until the deposit has been received.

Because appointment times are reserved exclusively for you, we kindly request at least 48 hours' notice for cancellations or rescheduling requests.

Cancellations made less than 48 hours before the scheduled appointment are not eligible for a refund. However, we understand that circumstances may be beyond your control. In these situations, your deposit may be applied as a credit toward a future appointment, provided that the new appointment is booked and completed within three (3) months of the original appointment date.

If an appointment is not rescheduled within the three-month period, the deposit will be forfeited.

Clients who fail to appear for their appointment without notice ("no-shows") will forfeit their deposit and may be required to pay a new deposit before scheduling future services.

We value your time and ask that you value ours. By honoring scheduled appointments and providing adequate notice when changes are necessary, you help us continue providing thoughtful, personalized care to every client we serve.

Thank you for your understanding and cooperation.

Beautélanin™ Skincare

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