Medical Aesthetician School NJ Online Questionnaire - A Medical Spa

Name *

First

Last

Address *

Street, City, State, Zip

Home Number *

Use numbers. No symbols. Example: 9858500

Cell Number *

Use numbers. No symbols. Example: 9858500

Email *

1. Do you currently hold a valid NJ Skin Care or Cosmetology license? Or, do you hold a valid license for RN, NP or PA? *

YES
NO

2. Please list the name and address of where you attended Skin Care and/or Cosmetology School, or College/University: *

3. What year did you graduate (above) schooling and what year did you get your license(s)? *

4. Are you currently working in a spa, medical spa or medical office/hospital setting? *

YES
NO

5. Where are you currently working? *

If not working enter N/A

a. How long have you been at your current position? *

b. Please list your current job responsibilities: *

If not working enter N/A

6. Have you had any working experience with microdermabrasion machines? *

YES
NO

a. If yes, which machine(s) and for how long? If no experience with microdermabrasion machines enter N/A *

7. Which Skin Care lines have you worked with? Please list all. *

8. Of all of the Skin Care lines you have worked with, which do you prefer and why? *

9. Do you have experience working with peels? *

YES
NO

If yes, please list all peels you have experience using and the results you have achieved with your client’s skin. *

If you have no experience working with peels place N/A

10. Why are you interested in taking this course, and what do you hope to learn? *

11. What are your professional goals within the next 5 years? What is your ultimate goal or your dream job? *

12. Why is now the right time for you to participate in this course? *

13. What are you the most excited to learn? *

14. What motivates you to reach your goals, personally and professionally? *

15. Describe your background (outside of your current position) in the medical, aesthetics, health or wellness fields, if any. *

16. How would you describe yourself? *

17. Are you aware that completion of this course does not guarantee you a position or job with Dr. Wilcox or otherwise? *

YES
NO

18. This is a hands-on course and is designed for you to work with/on instructors and classmates. Are you willing to work with/be worked on by everyone regardless of race, age, gender, religious or sexual orientation? *

YES
NO

19. Are you aware of the importance of attending all classes and that there will be no make-up classes or review of information missed by you, for any reason? *

YES
NO

20. If required, will you be able to bring a model to be worked on for any segment of the curriculum? *

YES
NO

21. Please list any/all allergies *

If no allergies type in N/A

22. Please list all medications you are currently taking, including any topical skin medications. *

If no allergies type in N/A

23. Have you ever been on any of the following medications, list dates: *

YES
NO

Diferin

Tazorac

Accutane

Retina A

24. Are you currently under a physician’s care for any medical condition, contagious disease or skin disorder? *

YES
NO

Have you ever experienced true Keloid scarring? *

YES
NO

Have you ever experienced a cold sore or any type of herpetic outbreak? *

YES
NO

* If you answer yes, you may need to use an antiviral medication before certain hands-on training procedures.

25. Please tell us how you found our program? *

A Medical Spa
Online / Google Search
Other / Please describe below

26. Please describe in more detail how you found our program? *

* By completing/submitting this form, I acknowledge that I am initiating contact with The Integrative Medical Aesthetics Program of NJ directly and this constitutes your express written consent to be called, texted, emailed by The Integrative Medical Aesthetics Program of NJ and / or their representatives at the number(s) / email(s) you provided. The Integrative Medical Aesthetics Program of NJ is independently owned by Dr. Donna Wilcox.

Admissions

Medical Aesthetics Program

Apply - Online Questionnaire