Lip Blush Consent Form

First name

Last name

Email

Phone

Birthday

Address

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?

Yes

No

Have you received chemotherapy or radiation in the past year?

Yes

No

Are you currently pregnant?

Yes

No

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

Yes

No

List any medications you have been taking in the past 6 months