How Did you Find Us?
Are you currently under the care of a Physician? Yes No
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? Yes No
Do you have any of the following medical conditions? (check all that apply)
Frequent cold sores
Blood clotting abnormalities
Any active infection
High blood pressure
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)
Birth Control pills
If others, please explain:
Are you on any mood altering or anti-depression medication? Yes No
If yes, please list:
Have you ever used Accutane? Yes No
Have you ever had laser hair removal? Yes No
Have you had any recent tanning or sun exposure? Yes No
Do you form thick or raised scars from cuts or burns? Yes No
Do you have Hyperpigmentation (darkening of the skin), or Hypopigmentation (lightening of the skin or marks) after physical trauma? Yes No
If yes, please explain:
Have you ever had local anesthesia with lidocaine? Yes No
Are you pregnant or trying to become pregnant? Yes No
Are you breastfeeding? Yes No
Are you using contraception? Yes No
Which of the following best describes your skin type?
Always burn, never tan
Sometimes burn, always tan
Rarely burn, always tan
Brown, moderately pigmented skin
Heavily pigmented skin, very dark hair
Do any of the following concern/ / interest you? Please check all that apply
Wrinkles / Fine Lines
Dry / Rough skin
Uneven Skin Tone
Your Current Weight
Loss of Firmness / Elasticity
I give permission to the Lip Doctor to take photographs before treatment and at all other sessions after treatment and at all other sessions. I acknowledge these photographs are for the purpose of evaluating the effectiveness of my treatment and will only been seen my myself and staff of the Lip Doctor for my medical records. I agree I refuse
The Lip Doctor would appreciate the opportunity to show your before and after results with other clients. Please check off what you are comfortable with.
Eyes Blacked Out
Not at all
The Lip Doctor would appreciate the opportunity to show your before and after results on our website and social media.
Eyes Blacked Out
Not at all
If any appointment is not cancelled at least 24 hours in advance you may be charged a fifty dollar ($50.00) fee; this will not be covered by any credit and/o prepaid package.
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 detai