Personal Information:

*Mandatory Fields

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:

Medications:

*Mandatory Fields

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

If yes, when did you last use it?:

History:

*Mandatory Fields

* 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:

*Mandatory Fields

* 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

CONSENT FOR PHOTOGRAPHS:

*Mandatory Fields

* 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.

I acknowledge

* 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?

Yes
No

* The Lip Doctor would appreciate the opportunity to show your before and after results on our website and social media. Do you consent?

Yes
No

Acknowledgement:

* I acknowledge that I have read and understood the questions above and answered them to be true.

I acknowledge

* Print your full name to sign:

Cancellation / No Show Policy:

* 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.

I acknowledge

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.

I acknowledge

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 details.

I acknowledge