Lip Blush Model Invitation List
Please provide your details and preferences to help us customize your treatment.
Client Details
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Treatment Interest
Have you had lip blush or lip filler before?
*
Yes
No
When was your last treatment?
Any complications or reactions?
Model Slot Application (if applicable)
Are you applying for a model slot?
Yes
No
Please confirm you understand the following:
This treatment may be discounted or free
Extra time may be required
Photos/videos will be taken for training and marketing
Results may vary
You may not choose exact pigments or style
Do you consent to being filmed/photographed?
Yes
No
Why would you like to be selected as a model?
Medical History
Do you have any of the following? (tick all that apply)
*
Cold sores (herpes simplex)
Diabetes
Autoimmune conditions
Blood disorders
Heart conditions
Skin conditions around the lips
Keloid scarring
Allergies (especially to numbing agents or pigments)
Pregnancy or breastfeeding
None of the above
Please provide details if selected:
Medications & Lifestyle
Current medications (including Roaccutane, antibiotics, blood thinners)
Supplements
Smoking
Yes
No
Alcohol
Yes
No
Contraindications & Safety
Lip filler in last 4 weeks?
Yes
No
Roaccutane in last 6–12 months?
Yes
No
Recent cosmetic procedures?
Yes
No
History of fainting?
Yes
No
Lip Assessment
How would you describe your lips?
Pale
Dark / cool-toned
Uneven pigmentation
Dry / chapped
Asymmetrical
Desired Results
What are you hoping to achieve?
More defined border
Improved symmetry
Brighter / even tone
Natural enhancement
Lipstick effect
Preferred style
Very natural
Soft blush
Defined colour
Colour preference
Nude
Pink
Coral
Unsure
Photo & Content Consent
I consent to before & after photos
*
Yes
No
I consent to images/videos being used for marketing
*
Yes
No
Priority Waitlist
Would you like to join our priority waitlist for:
Last-minute cancellations
Model opportunities
Exclusive discounted slots
New treatment launches
Join waitlist?
Yes, add me to the priority list
No, not at this time
Preferred contact method
SMS
Email
Acknowledgement & Consent
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Consultation
Submit Consultation
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