Medical Intake Form First NameLast NameDate Of BirthPhone/MobileEmailSkin Type Normal Dry Oily CombinationPreviousNextPregnant or Breastfeeding Yes NoAllergies (including latex, lidocaine, or pigments) Yes NoPlease Specify Type of Allergy :Diabetes Yes NoPlease Specify Type of Condition :Are you currently using Accutane or any isotretinoin products? Yes NoAre you currently using Exfoliating products/Retinol/Peels on the lips or surrounding area? Yes NoDo you have any blood disorders or take blood-thinning medications (aspirin, ibuprofen, fish oil, etc.)? Yes NoDo you have a history of cold sores / fever blisters? Yes NoHave you taken antiviral medication before appointments in the past? Yes NoPreviousNextDo you smoke? Yes NoHow often do you drink caffeine or alcohol? Daily Occasionally NeverHow often do you hydrate (water intake)? High Moderate LowDo you frequently bite, lick, or peel your lips? Yes NoPreviousNextWhich look do you prefer? Natural / Soft Tint Ombre / Gradient Bold / Lipstick EffectPreferred color(s) ?Image Upload (Attach Reference Photos)Choose File Are you okay with a touch-up session 6–8 weeks after your first appointment? Yes NoPreviousNext I understand that: Lip blush is a semi-permanent procedure and results vary depending on healing and skin type.Healing may include peeling, scabbing, or pigment fading.Touch-ups are recommended for best results.I have disclosed all medical history, allergies, medications, and lifestyle habits truthfully.I understand the aftercare instructions and will follow them to ensure proper healing. Previous Submit Form
