* Month of Birth
How Did you Find Us?
Are you currently under the care of a Physician?
If yes, name of Physician and what for?
List of Past Surgeries:
List of Medications Vitamins and Supplements:
Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately inteheat or infrared irritation?
Do you have any of the following medical conditions? (check all that apply)
Do you have any other health problems or medical conditions? Please list:
Have you ever had an allergic reaction to any of the following? (check all that apply)
If other, please explain:
If food, please explain:
What oral/topical medications are you presently taking? (check all that apply)
If others, please explain:
* Are you on any mood altering or anti-depression medication?
If yes, please list:
* Have you ever used Accutane?
If yes, when did you last use it?:
* Have you ever had laser hair removal?
* Have you had any recent tanning or sun exposure?
* Do you form thick or raised scars from cuts or burns?
* Do you have Hyperpigmentation (darkening of the skin), or Hypopigmentation (lightening of the skin or marks) after physical trauma?
If yes, please explain:
* Have you ever had local anesthesia with lidocaine?
* Are you pregnant or trying to become pregnant?
* Are you breastfeeding?
* Are you using contraception?
* Which of the following best describes your skin type?
Do any of the following concern/ / interest you? Please check all that apply
* I understand that The Lip Doctor will take mandatory photographs before and after each treatment in order to properly document progress and effectiveness of the procedure. I acknowledge these photographs are for the purpose of evaluating the effectiveness of my treatment and will only be seen by myself and staff of the Lip Doctor as part of my medical records.
* The Lip Doctor would like the opportunity to show your treatment results during consultations to individuals seeking similar treatments to help them make better informed decisions. Your image will not be shared or provided to them at any point just shown by a staff member on their personal tablet. Do you consent?
* The Lip Doctor would appreciate the opportunity to show your before and after results on our website and social media. Do you consent?
* I acknowledge that I have read and understood the questions above and answered them to be true.
* Print your full name to sign:
* Your appointment time is reserved just for you. A late cancellation or missed visit leaves space in our schedule that could have been filled by another client. As such, we require 48 hours notice for any cancellations or changes to your appointment. Clients who provide less than 48 hours notice, or miss their appointment, will be charged a cancellation fee of $50. Thread lifts require a 10% deposit when booking. The deposit is not refundable if less than 48 hours notice is given for cancellation.
* We understand that delays can happen however we must try to keep the other patients and doctors on time. If a patient is 15 minutes past their scheduled we will do our best to accommodate the appointment; although in rare cases we may have to reschedule.
* Products sold without service provider prescription are final sale. Products sold with service provider prescription are subject to exchange only. We custom each package for individual needs and concerns of our patients. Packages are created for optimal success. In the special circumstance that you are unhappy the results we can offer, at our discretion, a package conversion. At the time of request, we may convert the remainder of your current package to a dollar amount and apply it as a credit towards another treatment. Any questions or concerns please don’t hesitate to ask your Lip Doctor provider for further details.