Full Name *

Email *

Phone *

1. What is your main goal right now? *

A. I want fuller, more defined lips

B. I want to reduce fine lines or wrinkles

C. I want to improve my skin

D. I want my face to look more balanced overall

2. What bothers you the most when you look in the mirror? *

A. My lips feel thin, uneven, or lack shape

B. I recently noticed wrinkles on my face

C. My skin looks dull, dry, and textured

D. My features feel slightly off or not as harmonious as they could be

3. What kind of result are you looking for? *

A. Subtle but noticeable lip enhancement

B. A smoother, more refreshed appearance

C. Hydrated, even and healthy skin

D. A more sculpted, balanced facial structure

4. Have you had treatments before? *

A. Yes, lips or I am very interested in starting with lips

B. Yes, Botox or I am curious about trying it

C. No, but I am interested in improving my skin first

D. I am open to a customized plan based on my face

5. Which statement sounds most like you? *

A. I want my lips to look fuller, more symmetrical, or more defined

B. I want to soften lines and prevent aging from progressing

C. I want that “glow” and better skin quality without looking overdone

D. I want to look like a more balanced, elevated version of myself

JAIOUX CLINIC

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