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Cosmetic Interest Questionnaire
Please provide the following information to receive a custom aesthetic treatment plan.
Name
*
First Name
Last Name
Date of Birth
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
Year
E-mail
*
example@example.com
Phone Number (Only include numbers)
*
-
Area Code
Phone Number
Instagram Handle
*
@instagram
How did you find me?
*
Instagram
Facebook
Search engine (google, yahoo)
Patient referral
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Aesthetic Motivation
Do you have a Injector Preference
*
Jen
Tetchie
Stephanie
Mckenzie
First Available
What is your primary motivation for seeking cosmetic treatment?
*
Do you have an upcoming event or vacation you want to look your best for?
-
Month
-
Day
Year
Event Date
To what extent do you feel your feature(s) are currently ugly, unattractive or ‘not right’?
*
Very ugly or 'not right'
Markedly unattractive
Moderately unattractive
Slightly unattractive
Not at all unattractive
How often do you do you deliberately check your feature(s)? Not accidentally catch sight of it.
*
About 40 times or more a day
About 20 times or more a day
About 10 times or more a day
About 5 times or more a day
Never check
To what extent does your feature(s) currently cause you a lot of distress?
*
Not at all distressing
Slightly distressing
Moderately distressing
Markedly distressing
Extremely distressing
Identity Assessment
I desire a facial structure that aligns with
1
2
3
4
5
Feminine
Masculine
1 is Feminine, 5 is Masculine
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Skin
Describe how your face feels when you cleanse & let it dry for 20 minutes without applying anything to it:
*
Tight
Normal
Oily/Shiny
Irritated/ Red
Other
Describe your skin concerns:
*
Acne Prone
Hyperpigmentation/ Dark Spots
Fine Lines
Cystic Acne
Rosacea/ Redness
Hypopigmentatiom
Milia
Acne Scarring
Sun Damage
Large Pores
Broken Capillaries
Patchy Dryness
Uneven/Blotchy
Not Sure
Are you currently or have you previously received the following skin care treatments?
*
Facial Peel
Microdermabrasion
Dermaplaning
Permanent make-up/tattooing/microderm pigmentation
Lasers
Morpheus, Profound, Sylfirm RadioFrequency Microneedling
Microneedling
None
If so, when and what treatments?
Are you currently under the care of a Dermatologist?
*
Yes
No
pending appointment
Are you prescribed any RX topicals that you apply to you face?
*
Yes
No
If so, what are they?
List name, strength, dose and frequency of use.
Morning Skincare
*
List your AM skincare in order of application
Do you have a product to reapply your sunscreen throughout the day?
*
No
Brush-on Powder sunscreen
Spray Sunscreen
Cream Compact Sunscreen
Other
Evening Skincare
*
List your PM skincare in order of application
Are you currently using any skincare products that contain active ingredients (Glycolic/Salicylic Acid, Vitamin A)?
*
Yes
No
Has any skincare product ever caused a bad reaction?
*
Yes
No
If yes, what product and describe reaction:
Describe ingredient allergies, breakouts, rashes, etc
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FACE
Please describe your face shape:
*
Round
Oval
Square
Heart Shape
Have you had surgery on your face or neck?
*
Yes
No
If yes, please describe the type of surgery & date:
Do you have any implants in your face?
*
Yes
No
Neuromodulators
Botox, Dysport, Xeomin, Daxi
Do you currently have any of the following static lines?
*
Forehead Wrinkles
Frown Lines
Bunny Lines
Crow's Feet
Nasolabial Folds (nose to mouth lines)
Vertical Lip Lines (Smoker's Lines)
Marionette Lines (concerns of mouth to jaw)
None
Have you ever been treated with Botox/Dysport?Xeomin?
*
Yes
No
If so, have you had adverse effects from your neuromodulator treatment?
Do you clench your jaw or grind your teeth?
Yes
No
Unsure
Fillers
Restylane, Juvederm, RHA, Versa, Radiesse, Bellafill, Artefill
Have you ever been treated with any of the following?
*
Hyaluronic Acid Dermal Filler (Juvederm, Restylane, Versa, RHA)
Calcium Hydroxyapatite (Radiesse)
Sculptra (PLLA)
Silicone Injections
Bellafill
Artefill
Other
If so, please list when, what areas and the injector?
Have you ever had dermal filler dissolved?
*
Yes
No
Do you have history of cold sores or fever blisters?
*
Yes
No
Comments
Biostimulators
Sculptra, PRP, PRF, EzGel/Biofiller, Exosomes
Have you ever been treated with any of the following?
*
Sculptra (PLLA)
Hyperdilute Radiesse (CaHA)
PRP
PRF
PRF EzGel or BioFiller
Exosomes
No
Other
If so, when and what areas?
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Next
Take a Photo
Please stand in front of a window and take two photos without any makeup, filters or facial expression.
Facing the camera (anterior)
*
Looking to the side (Profile)
*
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Goals & Outcomes
Describe your favorite features:
*
Describe your primary concerns:
*
Describe the outcome you would like to achieve from aesthetic treatments:
*
Select the option that works best with your social calendar and budget. Jen will develop a virtual treatment plan for the option you chose.
*
A single balancing appointment with Jen that front loads your treatment plan on the first visit ($3500 - $5000)
A step-wise approach with segmented areas and filler appointments spread out every 3-4 months with an injector on Jen’s team. ($1700-$2550)
Single area appointments like Botox or lips with one of the injectors on Jen’s team ($850)
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