Lip Blush Medical Form

Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?

Yes

No

Have you received chemotherapy or radiation treatment in the last year If you answered yes to the above, please provide your Doctors name and surgery address

Yes

No

Have you ever had any Dental injections to numb your mouth?

Yes

No

Are you presently pregnant or breast feeding? (We can’t do treatment for pregnant or breastfeeding women)

Yes

No

Do you have MRI scan scheduled in the next 3 months?

Yes

No

Do you have Laser or IPL scheduled in the next 3 months?

Yes

No

Do you give blood?

Yes

No

Prior to dental procedures do you receive antibiotic therapy?

Yes

No

I have had Botox or other injectables.

Yes

No

Are you currently under the care of a doctor or hospital specialist? (If yes you will need GP referral)

Yes

No

Have you had semi permanent make up before?

Yes

No

Thanks for submitting!