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? *

Cancellation Policy: We value your business and ask that you respect our business scheduling policy. Please notify us at least 24 hours prior to your appointment time and we will gladly reschedule your reservation. If you reschedule or cancel within 24 hours of your appointment time, or a no show, you will be charged the full price of your appointment. Please understand that when you forget about or cancel your appointment without giving enough notice, we miss the opportunity to fill that appointment time. Our appointments are confirmed 48 hours in advance to help remind you. Because the service is reserved for you personally, a cancellation fee will apply. *

By signing you agree that all information you have provided here is true and correct.

OFFICE USE ONLY: MEDICAL DIRECTOR SIGNATURE

Office Use Only. Medical Director Signature