Lip Blush Appointment Form

Please note: At this time I am not doing lip neutralizations but plan to in the near future. If you are someone with melanin/hyperpigmentation in your lips and you'd still like to fill out the form and be added to a waitlist to be notified when I will be offering this service, please feel free! Thank you!
Name*

First NameLast Name
Email*
example@example.com
Birth Date*

MonthDayYear
Do you or have you ever had any of the following health or skin concerns - especially in the area being tattooed - that I should be aware of? (Check all that apply)

Cold Sores/Fever BlistersAcneEczemaPsoriasisMoles/BirthmarksCancerChemotherapyOther
If other, please explain:
IMPORTANT: If you have ever had a cold sore or fever blister even once in your life you MUST take an anti-viral medication such as Valtrex for a few days prior to your appointment and for a few days after the procedure to prevent an outbreak (or as directed by your physician).
Have you ever had your lips previously tattooed?*

YesNo
What look are you hoping to achieve with this procedure?*

Light - More like a lip stain or a lip tintFull Coverage - More like lipstick
Additional Questions:
Please submit clear photos of your bare lips (no makeup, no filters) as well as any lip color inspiration you may have. Photos should be taken in good lighting, preferably natural light, I recommend taking the photo facing a window during the day.*

Cancelof
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