Client Intake Questionnaire - JustJill Cosmetics

Client Name *

First

Last

Email *

Phone *

Cell Provider *

Date of Birth (MM/DD/YYYY)

How did you hear about us? *

Medical History

Do you have any of the following medical conditions? Please check all that apply. *

Please list any other health or medical conditions you may have *

List any Prescription drugs (topical or internal) *

Examples: Retin-A, Accutane (last yr), Antibiotics, Cigarettes, Stimulants, Diuretics, Oral Contraceptives

Have you used Retin-A in the last week? *

Have you had cosmetics surgery? (copy) *

If yes, please list it here: *

Laser, Botox, Fillers, etc.

FEMALE CLIENTS: Are you pregnant? *

Lifestyle

Occupation:

What is your stress level (1-5) *

Do you exercise? *

Please list all of the supplements and mg you take per day:

Daily intake of Water in ounces? *

How many cups of Coffee? How do you take it? *

How many cups of Tea? Sweet, Unsweet, Herbal or Black? *

Soda? *

Alcohol: Drinks per week? *

Your Skin & Experiences

Skin Condition: *

If selected other, please describe here:

Do you experience skin breakouts? *

Skin Care Routine

Skin Care Routine: *

From the above list, please list all of the products you use for your Skin Care Routine *

For Example, Cleanse: Olay cleanser Tone: Seabreaze Exfoliate: Almond scrub.

Allergies (food/ other): *

Have you ever had a reaction to any skincare treatments before? *

If yes, please describe treatment and reaction.

What are your skincare goals? *

I agree that all information provided here is true and correct.

Initial

Cancellation Policy: I understand and agree to follow the appointment cancellation policy. I agree to provide a minimum of 24 hours notice to change or cancel my appointment. If I do not provide 24 hour notice for cancellation, and the spa is unable to fill my appointment time, I authorize my credit/debit card on file to be charged a $50.00 fee (or the price of the scheduled service if it is lower). If I do not show for a scheduled appointment, I authorize my debit/credit card on file to be charged for the full price of the service scheduled. All appointments are confirmed 48 hours in advance by text and/or email according to customer preference, but it is my responsibility to keep my scheduled appointments regardless if I receive a confirmation message or not. *

Client signature authorization

OFFICE USE ONLY: MEDICAL DIRECTOR SIGNATURE

Office Use Only. Medical Director Signature