Personal Information:

General Information:

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)
Cancer Frequent cold sores Seizure disorder Blood clotting abnormalities Diabetes HIV/AIDS Hepatitis Any active infection High blood pressure Keloid scarring Hormone imbalance Herpes Skin diseases/lesions Thyroid imbalance Arthritis

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)
Hydrocortisone Hydroquinone Lidocaine Latex Aspirin Food Other

If other, please explain:

If food, please explain:


What oral/topical medications are you presently taking? (check all that apply)
Birth Control pills Hormones Others

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

Female Clients:

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 Double Chin Nasolabial Folds Sun Damage Age spots Acne Scars Large Pores Broken Capillaries Rosacea Dry / Rough skin Uneven Skin Tone Dark Circles Hyperpigmentation Melasma Hair Loss Dry Eyes Joint Pain Migraines Your Current Weight Fat Reduction Spider Veins Stretch Marks Loss of Firmness / Elasticity Skin Tightening Sexual Dysfunction Painful Intercourse Vaginal Pain Vaginal Dryness Vaginal Laxity Vaginal Discharge Vaginal Itchiness Vaginal Rejuvenation Vaginal Burning Urinary Incontinence Painful Urination


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.
Full Face Half Face 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.
Full Face Half Face Eyes Blacked Out Not at all

Cancellation / No Show Policy:

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.

Scheduled Appointments:

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.

Refund/Package Conversion Policy:

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