LIP BLUSH HEALTH PRE-SCREEN FORM
A non-refundable booking fee of $50 is required to schedule an appointment. The booking fee will be used as a guarantee for your appointment and will be applied towards the total cost of your service. Should you not show up, arrive more than 15 minutes late, or cancel/reschedule without 48 hours notice, your booking fee will be forfeited. No exceptions. Please fill out and submit the following Pre-Screening Questions. Your form will be reviewed within 12 hours after submission. I will contact you via email/text to confirm you are in a good health state to proceed with the Brow / Lash tattoo procedure. If we do find you are not an appropriate candidate for the lip / brow tattoo your $50 deposit will be refunded to you and your appointment will be cancelled immediately. If you have questions, please reach out to me prior to booking your brow/lip appointment.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Please check ALL boxes that apply. If you answer yes to any of these questions, please speak to me before booking.
*
Pregnant
Diabetic
Lupus
Epileptic / Prone To Seizures
Organ Transplant
Heart Conditions or Pacemaker
Chemotherapy within the last year (including chemo medication)
History of Keloids
Contagious Diseases and Viral Infections (ex. HIV / AIDS)
Autoimmune Disorders (must have doctor's consent)
Botox or fillers in the lip area in the last 4 weeks
Taken Accutane (or other acne medication) within the last year
Active skin condition such as Psoriasis or Eczema in the lip area or near lip area
Allergies to topical anesthesia
Allergies to metals (iron / nickel / steel)
Recently tanned or sunburned on or near the lip area
Use of active ingredients within 4 weeks (Retin-A, Retinol, Glycolic Acid, AHA)
Currently taking blood thinners (including Omegas and Vitamin E)
Have a history of Cold Sores
None of the Above
Please list any other medical conditions that apply to you that are not listed above.
Please list all medications, vitamins, and supplements taken in the past 6 weeks. Indicate which ones are current. If not applicable simply type N/A.
Do you have any allergies
*
Yes
No
If yes to the above question, please list allergies below:
Do you have any previous lip tattoo?
*
Yes
No
If yes, how long ago?
I understand if I have a history of Cold Sores virus, the Lip Blush procedure may potentially cause a reactivation and outbreak on the treated area. I understand that if I get a cold sore flare-up, it is my responsibility to contact my doctor immediately and my lip blush technician and Marveleyes Inc. is not liable.
*
Yes
No
I hereby certify that this information is accurate and if any of the above changes, it is my responsibility to inform the technician of Marveleyes Inc. of any changes in my above information.
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: