Fitzpatrick Skin Type Matrix
This form is to classify patients' skin type as an assessment before light therapy. Doing this before seeing the doctor will help us provide you with the best results possible.

If you are interested in getting Laser or BBL treatment, please fill out and submit this Fitzpatrick skin type form, medical history form, and either laser or bbl consent form. There are two different forms for Laser and BBL--please choose accordingly. All of these forms are located at the "Forms" tab on the website. (g2jclinic.com) Filling out and submitting all these forms before coming to the office will waive the $250 consultation fee.

G2J Clinic Inc,
5150 Graves Ave. San Jose, CA 95129
408-253-8000
g2jclinic.com

Name *
Your answer
Date of Birth *
Your answer
Email or Phone number *
Your answer
1) My ethnic origin is closest to: *
2) My eye color is: *
3) My natural hair color at age 18 was: *
4) The color of my skin that is not normally exposed to sun is: *
5) If I go out into the sun for an hour or so without sunscreen and have not been out in the sun for weeks, my skin will: *
6) When was the last time the area to be treated was exposed to natural sunlight, tanning booths or artificial tanning cream? *
Please go back to your answers for questions 2-6. Add the numbers altogether in ( ). This number is your total score.
Please enter your skin type based on your total score. *
If you sustain an injury to your skin such as a cut, burn, or bruise, how long does it take to fully resolve without any hyperpigmentation? *
Your answer
What happens if you get an insect bite? *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service