Hyperpigmentation treatment consultation form: what UK therapists should record
A hyperpigmentation consultation form should record when the patches appeared, likely triggers such as sun, pregnancy or hormonal medication, the client's skin type, what has been tried before, and signed agreement that results are not certain and that treatment can make pigmentation worse. No UK law prescribes the form, but it is your main evidence that you asked, explained and advised.
Why pigmentation clients need their own consultation
A general consultation form asks about health and allergies. A client booking for dark patches also needs you to ask why the patches are there, because the cause changes what is sensible to offer. The British Association of Dermatologists describes melasma, one common type, as brown or greyish patches that usually develop on the face, and says it is more common in women, particularly in pregnancy.
No UK law sets out a hyperpigmentation form. What exists is your insurer's terms, your product manufacturer's protocol and your duty to treat with reasonable care. A dated, signed record of what you asked and explained is what you will want to produce if a client later says their skin got worse. Check your own policy wording, because some insurers specify what the record must hold.
Questions that help you understand the cause
Ask these as direct questions on the form, in the client's own words, and note the answers rather than guessing.
- When the patches first appeared, and whether they have changed since.
- Pregnancy, hormonal contraception or HRT. The BAD lists pregnancy and hormonal drugs such as birth control pills and hormone replacement among the things that can contribute to melasma.
- Sun and sunbed use. The BAD says UV light from the sun and the use of sunbeds can trigger melasma or make it worse.
- Medication, including anything your manufacturer lists as making skin sensitive to light.
- What has already been tried, including prescribed creams, acids, peels and devices, and how the skin responded.
- Any new or changing moles or marks in the area (see the next section).
When to refer rather than treat
You cannot diagnose, and the form should not pretend to. A pigment concern that is really a mole needs a GP, not a facial. The NHS says a new mole or a change in an existing mole may be a sign of melanoma, that a mole that changes size, shape or colour may be a melanoma, and that any change to a new or existing mole should be checked by a GP.
Put a clear question on the form about new or changing moles or marks, and a box for "advised to see GP" with the date. If the client is unsure what a patch is, record that you suggested they have it checked before you treat. This protects the client first and you second.
Sun protection and why results can come back
Pigmentation work often fails because of sun rather than because of the treatment. The NHS recommends at least factor 30 sunscreen with at least 4-star UVA protection. The BAD leaflet on melasma advises a sunscreen of at least SPF 30 with 5 UVA stars, applied before going out and reapplied every two hours when outdoors, and says melasma often returns after treatments stop.
Build that into the consent. Ask the client to tick that they will use daily sun protection, and that you have explained results may fade or return. Do not promise a result: pigmentation behaves differently from person to person.
Treatments that can make pigmentation worse
The BAD says laser and chemical peels can worsen pigmentation or leave patches of lighter skin, more often in people of colour, and that such procedures should only be done by highly experienced practitioners. An NHS hospital leaflet on microneedling for scars tells patients their skin pigment may change temporarily or permanently and may get lighter or darker.
Record the client's skin type, explain the risk in plain words before you start, and follow your manufacturer's protocol for that skin type. A client treated for dark patches who was never told a treatment could darken or lighten the skin has a strong complaint. See our guides to chemical peel consent, patch testing and documenting a reaction.
Photographs and keeping the record
Before and after photographs are the best evidence of how skin looked at the start, but they are also personal data and need the client's consent for the specific purpose. Our guide to photo consent covers the wording, and our guide to handling client data covers storage.
What a hyperpigmentation consultation form should ask
A preview of our free Hyperpigmentation Assessment and Consent Form. The complete, print-ready version is sent to you by email.
Client details
- Full name
- Date of birthDate
- + 2 more in the full form
Pigmentation history
- When did you first notice the patches?Date
- Where are the patches, and have they changed in size, shape or colour?Free text
- + 2 more in the full form
Medical history
- Are you pregnant, breastfeeding or trying to conceive?Yes / No
- Do you take hormonal contraception or HRT?Yes / NoIf yes, which one
- + 5 more in the full form
Skin assessment (completed by your therapist)
- Skin type (Fitzpatrick scale)I · II · III · IV · V · VI
- Pattern, colour and depth of pigmentation observedFree text
- + 2 more in the full form
Your understanding and consent
- The treatment and its likely results have been explained to me, and I understand results cannot be promisedYes / No
- I understand treatment can make pigmentation darker or lighter, and that this may be long lastingYes / No
- + 5 more in the full form
The full form has 26 questions in 5 sections, a signed declaration and space for your business details. Get it free below.
Free template
Get the print-ready Hyperpigmentation Assessment and Consent Form
The complete form, print-ready, with space for your business details, a pigmentation history, skin assessment, tick boxes and both signatures. Free, and yours to adapt.
Frequently asked questions
Is a hyperpigmentation consultation form a legal requirement?
No specific UK law requires one. Most insurers expect a written consultation and consent, and without it you have little evidence of what you asked and explained. Check your own policy wording.
Should I treat dark patches I cannot identify?
Do not diagnose. If a patch is new, changing, itchy or bleeding, or the client is unsure what it is, advise them to see their GP first and record that you did. The NHS advises getting any change to a mole checked by a GP.
Do I need a separate form for each treatment type?
A pigmentation assessment sits alongside your general consultation. Each treatment you then offer, such as a peel or microneedling, should still have its own consent that names that treatment's risks.
How long should I keep the form and photographs?
There is no single legal period. Decide a retention period you can justify, state it in your privacy notice and keep to it. Many insurers ask for records to be kept for several years, so check your policy first.
Sources
- Melasma patient information leaflet, British Association of Dermatologists
- Melanoma skin cancer: symptoms, NHS
- Sunscreen and sun safety, NHS
- Microneedling post-treatment information for patients, Chelsea and Westminster Hospital NHS Foundation Trust
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See the form packs, from £29 →These articles are general guidance for UK beauty therapists, not legal or medical advice. Our forms are editable templates: adapt them to your specific treatments, your product manufacturer's protocol and your insurer's terms.