Lip Blushing Intake & Health History

Check all that apply (past and present)

By signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform my esthetician of any changes to the information listed on all the pages of this client intake form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform my practitioner of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my practitioner and "COMPANY NAME HERE" for any injury or damages incurred due to my misrepresentation of my health history.

NOT pregnant or nursing and desire to receive the lip blushing procedure. 2.

I agree that I am over the age of 18, am NOT under the influence of alcohol or drugs, am

I understand that needles are used for the lip blushing procedure to inject color pigments

into the upper layers of the skin. 3.I have been informed of the nature, risks, and possible complications and consequences of lip blushing. I understand the lip blushing procedure may have known or unknown complications including but not limited to: minor to intensive swelling, tenderness, soreness, itchiness, burning, infection, scarring, inconsistent color, and spreading, fanning, or fading of pigments, and allergic reaction.

I understand that I may or may not experience certain side effects if an anesthetic is used including but not limited to allergic reaction, light-headedness, drowsiness, dizziness, vomiting, tongue numbness, and slow heartbeat. 5.I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin and will appear darker during the first few days immediately following the procedure. I understand that I will need a follow-up appointment and may require touch-up appointments. I request the lip blushing procedure(s) and accept the permanence of the procedure as well as the possible complications and consequences of the procedure. 8. Choose one: I consent(initial) or waive(initial) the patch test. I understand that if I have any skin treatments including but not limited to laser hair removal, plastic surgery, or other cosmetic procedures, it may result in adverse changes to my permanent cosmetics and may not be correctable. 10.I have received pre- and post care instructions and I will strictly adhere to such instructions. I understand that my failure to properly follow pre and post care instructions may compromise my procedure.

1. Consult with your primary care physician if you are prone to cold sores. If you are prone to cold sores, please inquire about taking an antiviral medication prior to having your procedure done. 2. Avoid certain cosmetic procedures before your lip blushing procedure including lip implants (not within 6 months of procedure) and no fillers within 3 weeks of procedure. 3. Please remove any oral piercings prior to the appointment and cleanse the area. 4. If you currently have a sinus infection, please contact your practitioner for further guidance. 5. Avoid smoking or antiobiotic therapy at least 4 weeks prior to appointment. If unavoidable, please contact your practitioner for further guidance as antiobiotics and smoking result in higher candida (yeast) count and infection may result. 6. Avoid alcohol and blood thinning medications at least 24 hours prior to procedure. 7. Avoid caffeine 12 hours prior to procedure. 8. Drink plenty of water to hydrate and keep lips supple. 9. Scrub your lips the day before the procedure to remove any dead skin buildup.

1. Use a clean and cool washcloth to gently wipe the lips in the morning, after eating, and before bed for at least 7 days post-procedure. 2. Apply a generous amount of A&D ointment or Aquaphor ointment with a clean q-tip as many times as necessary throughout the day to keep lips moist. 3. Use caution when brushing your teeth and avoid getting toothpaste on the lips.

4. Keep your lips sealed when washing your face and avoid getting your facewash or scrub on your lips. 5. Do NOT exfoliate, rub, pick, scratch, or peel at the lips. 6. Do NOT apply makeup until fully healed. 7. Avoid intense or direct sun exposure.

8. Avoid salty or spicy food and drink.

9. Avoid kissing until fully healed.