Lip Blush Consent Form

Birthday

Have you had any of the following?

Have you had an allergic reaction to the following?

Are you currently taking medications that thin the blood?*

Have you received chemotherapy or radiation in the past year? *

Are you currently pregnant?*

Have you received Botox, Lip Fillers, Restylane, Juvederm or collagen injections in the last 6 months?*