Lip Filler Form

1
Date
Date
Year
Month
Day
2
Name
First Name
Last Name
3
Email
example@example.com
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number
Please enter a valid phone number.
6
How did you hear about Mako Beauty?
Family/Friend
Facebook
Instagram
Google
7
What are your expectations for your visit?
8
Are you currently using any topical medications or creams?
YESNO
9
If yes, please specify below:
10
Have you ever had Botox/Filler?
YESNO
11
If yes, when did you last receive this treatment?
12
Any allergies?
13
Have you taken any Aspirin, Ibuprofen, Motrin, Tylenol, Blood thinners, o Alcoholic Beverages in the last 10 days?
YESNO
14
If yes to any above, please specify below.
15
How much water do you consume in a day?
16
How much caffeine do you consume in a day?
17
Have you had any facial surgery in the last 6 months?
YESNO
18
How many MM do you want on your appointment?
Please Select
Please Select
1mm
2mm
19
PLEASE AVOID PRODUCTS CONTAINING RETIN-A AND ANTI-AGING PRODUCTS. I recommend you cut down the usage 1 week prior to your treatment, this concerns facial area only. This concerns products that contain a significant amount of Vitamin A. Avoid topical products such as Tretinoin, Retin-A, Retinol, Alpha Hydroxy Acid, Beta Hydroxy Acid, 2 weeks prior to your appointment.* This field is required.
I agree
I do not agree
20
AVOID WAXING, BLEACHING, TWEEZING, OR HAIR REMOVAL CREAM on the area to be treated3 days prior to your procedure. Also avoid Primrose oil, Garlic oil, Ginko biloba, Ginseng, or Vitamin, ONE WEEK prior to your appointment.* This field is required.
I agree
I do not agree
21
Do not donate blood the day of your procedure. This may strain your body causing you to feel weak. There may be some issues regarding the contents of your blood the day after the procedure, so be sure to disclose that you have had Hyaluron Fillers* This field is required.
I agree
I do not
22
You cannot have other treatments that concern the dermal layer of your skin 2-4 weeks prior to your appointment. This includes but is not limited to: Injectable Lip filler, Face Fillers such as Juvéderm, Restalyn etc. Permanent Cosmetic Tattoos, Tatoo Lasers, Chemical Procedures/Facials, Laser Hair removal etc.* This field is required.
I have not
I have
23
Be sure to tell your Esthetician everything you consider to be even mildly important. Be aware that you are obligated to fill in additional information in your consultation about the state of your health and everything affecting that (such as pregnancy, nursing, any sort of hemoglobin or neurological disorders in your past) in the appointment.* This field is required.
I agree
I do not
24
COLD SORES: If you have previously had, or are unsure, you will need to get an antiviral medication from your doctor and take 2-6 weeks prior to your appointment and up to 7 days afterwards. As always consult your primary care physician first.* This field is required.
I agree
I do not
25
DO NOT CONSIDER THE RESULTS OF THE INITAL PROCEDURE TO BE FINAL. Some clients have experienced mild anxiety when they notice in the beginning, sometimes the treatment area may appear asymmetric. This is completely normal. It will most likely change quite significantly during the first month after your procedure. Keep in mind that the actual result can be evaluated correctly ONLY AFTER the touch up procedure has been performed. Touch ups can happen every 2 weeks.
I understand/agree
26
Be prepared for a little redness and swelling and/or Bruising on your facial/lip area that may occur just after the procedure. Keep in mind when making plans for the next couple of hours/day after your Hyaluron Pen Treatment.
I understand/agree
27
Scrub the night /week leading up to your appointment. Use a lip sugar scrub (sugar and coconut oil) toothbrush, or face cloth to gently exfoliate your lips and keep them hydrated with a lip balm. If you do not, it can affect the products penetration into the lips.
I understand/agree
28
DRINK 8 glasses of water every day for 2-week prior to your appointment if possible and continue to do so after your procedure. Sense this is a hyaluronic acid filler hydration is KEY. The more you hydrate, the juicer and more plump your lips will be!
I understand and Agree
29
If you come in dehydrated, we cannot move forward with your appointment for that day, dehydration can cause to lumps in the lips.
I understand/agree
30
Come to the procedure with minimal makeup! Normal daily makeup is fine, but I recommend avoiding any makeup on the area being treated. (No lip stick)
I understand/agree
31
There are certain medications that I recommend to not take 2 weeks prior to your appointment. Example, Aspirin, Motrin, Ibuprofen, Aleve, any other pain killers and medication that may have a strong effect on your body. Please always check with your doctor first.
I understand/Agree
32
CONSUMING ALCOHOL BEFORE THE APPOINTMENT: It is best to not have any sort of alcoholic beverage 48 hours before your appointment. Do not consume large amounts of alcohol the night before the procedure, or your appointment will need to be rescheduled and your deposit will be forfeited. (This will cause dehydration in the skin which can lead to product loss and lumps in the lips)
I understand/Agree
33
I certify/agree that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to obey all of the pre/post procedure instructions, I accept all responsibility.
YESNO
34
I consent to having before and after pictures/videos done to keep on my file and/or marketing purposes.(Before and afters are usually just of the lips only)
I agree
I do not agree
35
Signature
Should be Empty: