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Microblading San Antonio

Today's Date: April 1, 2026

Hello! Thank you for choosing Microblading San Antonio! Very excited to work with you! Please fill out this questionnaire. Its the best way to create a lip treatment for you. 

Please note the following  

Lip Blush and/or permanent makeup treatments are not suitable for the following candidates: 

  • All potential clients under 18 years old
  • Allergic to local anesthetic or pigment
  • Uncontrolled high blood pressure
  • Any blood diseases (hemophilia, sickle cell anemia, platelet disorders)
  • Type 1 and 2 Diabetes
  • Current viral infection or an infectious disease
  • Any skin infection in the lip area (including sunburn, skin rash, dermatitis, herpes simplex infection on the face, folliculitis)
  • Chemotherapy treatment in the last year
  • Pacemaker, severe heart disease, and/or artificial valves
  • Prone to keloid scars
  • Epilepsy
  • Acute hepatitis
  • Leukemia
  • Sarcomas
  • Rheumatoid arthritis
  • Multiple sclerosis
  • Scleroderma
  • Pregnant and/or breast feeding
First Client’s Name
First Name*
Last Name*
Phone*
First Client’s Date of Birth*
Date of Birth
Information
SKIN CONDITIONS: *
ECZEMA
PSORISIS
KERATOS PILARIS (rough patches and acne-like bumps)
DERMATITIS
ROSACEA
NONE
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL LIP APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
NONE OF THE ABOVE

WHAT LIP IS BEST FOR ME?

HAVE YOU HAD PREVIOUS PMU OR LIP TATTO?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN
IF YOU HAVE NORMAL SKIN PLEASE PICK YOUR PREFERRED LIP TREATMENT *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
OMBRE LIP (SATURATION OF PIGMENT CLOSEST TO LIP LINE AND SOFT FADE AS IT GETS CLOSER TO INNER LIP)
NOT APPLICABLE
COMBINATION BROW
IF YOU HAVE OILY, COMBINATION, OR LARGE PORES: PLEASE PICK YOUR PREFRERED LIP *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
NOT APPLICABLE
IF YOU HAVE MATURE, SUN-DAMAGED, WRINKLED SKIN. PLEASE PICK YOUR BROW OPTION BELOW *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK
NOT APPLICABLE

WHAT DO I WANT MY LIPS TO LOOK LIKE? *

IF YOU HAVE PREVIOUS LIP TATTOO OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
First Client’s Signature*
Second Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
SKIN CONDITIONS: *
ECZEMA
PSORISIS
KERATOS PILARIS (rough patches and acne-like bumps)
DERMATITIS
ROSACEA
NONE
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL LIP APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
NONE OF THE ABOVE

WHAT LIP IS BEST FOR ME?

HAVE YOU HAD PREVIOUS PMU OR LIP TATTO?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN
IF YOU HAVE NORMAL SKIN PLEASE PICK YOUR PREFERRED LIP TREATMENT *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
OMBRE LIP (SATURATION OF PIGMENT CLOSEST TO LIP LINE AND SOFT FADE AS IT GETS CLOSER TO INNER LIP)
NOT APPLICABLE
COMBINATION BROW
IF YOU HAVE OILY, COMBINATION, OR LARGE PORES: PLEASE PICK YOUR PREFRERED LIP *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
NOT APPLICABLE
IF YOU HAVE MATURE, SUN-DAMAGED, WRINKLED SKIN. PLEASE PICK YOUR BROW OPTION BELOW *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK
NOT APPLICABLE

WHAT DO I WANT MY LIPS TO LOOK LIKE? *

IF YOU HAVE PREVIOUS LIP TATTOO OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
Third Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
SKIN CONDITIONS: *
ECZEMA
PSORISIS
KERATOS PILARIS (rough patches and acne-like bumps)
DERMATITIS
ROSACEA
NONE
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL LIP APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
NONE OF THE ABOVE

WHAT LIP IS BEST FOR ME?

HAVE YOU HAD PREVIOUS PMU OR LIP TATTO?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN
IF YOU HAVE NORMAL SKIN PLEASE PICK YOUR PREFERRED LIP TREATMENT *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
OMBRE LIP (SATURATION OF PIGMENT CLOSEST TO LIP LINE AND SOFT FADE AS IT GETS CLOSER TO INNER LIP)
NOT APPLICABLE
COMBINATION BROW
IF YOU HAVE OILY, COMBINATION, OR LARGE PORES: PLEASE PICK YOUR PREFRERED LIP *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
NOT APPLICABLE
IF YOU HAVE MATURE, SUN-DAMAGED, WRINKLED SKIN. PLEASE PICK YOUR BROW OPTION BELOW *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK
NOT APPLICABLE

WHAT DO I WANT MY LIPS TO LOOK LIKE? *

IF YOU HAVE PREVIOUS LIP TATTOO OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
Fourth Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
SKIN CONDITIONS: *
ECZEMA
PSORISIS
KERATOS PILARIS (rough patches and acne-like bumps)
DERMATITIS
ROSACEA
NONE
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL LIP APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
NONE OF THE ABOVE

WHAT LIP IS BEST FOR ME?

HAVE YOU HAD PREVIOUS PMU OR LIP TATTO?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN
IF YOU HAVE NORMAL SKIN PLEASE PICK YOUR PREFERRED LIP TREATMENT *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
OMBRE LIP (SATURATION OF PIGMENT CLOSEST TO LIP LINE AND SOFT FADE AS IT GETS CLOSER TO INNER LIP)
NOT APPLICABLE
COMBINATION BROW
IF YOU HAVE OILY, COMBINATION, OR LARGE PORES: PLEASE PICK YOUR PREFRERED LIP *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
NOT APPLICABLE
IF YOU HAVE MATURE, SUN-DAMAGED, WRINKLED SKIN. PLEASE PICK YOUR BROW OPTION BELOW *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK
NOT APPLICABLE

WHAT DO I WANT MY LIPS TO LOOK LIKE? *

IF YOU HAVE PREVIOUS LIP TATTOO OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
Fifth Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
SKIN CONDITIONS: *
ECZEMA
PSORISIS
KERATOS PILARIS (rough patches and acne-like bumps)
DERMATITIS
ROSACEA
NONE
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL LIP APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
NONE OF THE ABOVE

WHAT LIP IS BEST FOR ME?

HAVE YOU HAD PREVIOUS PMU OR LIP TATTO?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN
IF YOU HAVE NORMAL SKIN PLEASE PICK YOUR PREFERRED LIP TREATMENT *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
OMBRE LIP (SATURATION OF PIGMENT CLOSEST TO LIP LINE AND SOFT FADE AS IT GETS CLOSER TO INNER LIP)
NOT APPLICABLE
COMBINATION BROW
IF YOU HAVE OILY, COMBINATION, OR LARGE PORES: PLEASE PICK YOUR PREFRERED LIP *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
NOT APPLICABLE
IF YOU HAVE MATURE, SUN-DAMAGED, WRINKLED SKIN. PLEASE PICK YOUR BROW OPTION BELOW *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK
NOT APPLICABLE

WHAT DO I WANT MY LIPS TO LOOK LIKE? *

IF YOU HAVE PREVIOUS LIP TATTOO OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
Sixth Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
SKIN CONDITIONS: *
ECZEMA
PSORISIS
KERATOS PILARIS (rough patches and acne-like bumps)
DERMATITIS
ROSACEA
NONE
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL LIP APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
NONE OF THE ABOVE

WHAT LIP IS BEST FOR ME?

HAVE YOU HAD PREVIOUS PMU OR LIP TATTO?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN
IF YOU HAVE NORMAL SKIN PLEASE PICK YOUR PREFERRED LIP TREATMENT *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
OMBRE LIP (SATURATION OF PIGMENT CLOSEST TO LIP LINE AND SOFT FADE AS IT GETS CLOSER TO INNER LIP)
NOT APPLICABLE
COMBINATION BROW
IF YOU HAVE OILY, COMBINATION, OR LARGE PORES: PLEASE PICK YOUR PREFRERED LIP *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
NOT APPLICABLE
IF YOU HAVE MATURE, SUN-DAMAGED, WRINKLED SKIN. PLEASE PICK YOUR BROW OPTION BELOW *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK
NOT APPLICABLE

WHAT DO I WANT MY LIPS TO LOOK LIKE? *

IF YOU HAVE PREVIOUS LIP TATTOO OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
Seventh Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
SKIN CONDITIONS: *
ECZEMA
PSORISIS
KERATOS PILARIS (rough patches and acne-like bumps)
DERMATITIS
ROSACEA
NONE
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL LIP APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
NONE OF THE ABOVE

WHAT LIP IS BEST FOR ME?

HAVE YOU HAD PREVIOUS PMU OR LIP TATTO?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN
IF YOU HAVE NORMAL SKIN PLEASE PICK YOUR PREFERRED LIP TREATMENT *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
OMBRE LIP (SATURATION OF PIGMENT CLOSEST TO LIP LINE AND SOFT FADE AS IT GETS CLOSER TO INNER LIP)
NOT APPLICABLE
COMBINATION BROW
IF YOU HAVE OILY, COMBINATION, OR LARGE PORES: PLEASE PICK YOUR PREFRERED LIP *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
NOT APPLICABLE
IF YOU HAVE MATURE, SUN-DAMAGED, WRINKLED SKIN. PLEASE PICK YOUR BROW OPTION BELOW *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK
NOT APPLICABLE

WHAT DO I WANT MY LIPS TO LOOK LIKE? *

IF YOU HAVE PREVIOUS LIP TATTOO OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
Eighth Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
SKIN CONDITIONS: *
ECZEMA
PSORISIS
KERATOS PILARIS (rough patches and acne-like bumps)
DERMATITIS
ROSACEA
NONE
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL LIP APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
NONE OF THE ABOVE

WHAT LIP IS BEST FOR ME?

HAVE YOU HAD PREVIOUS PMU OR LIP TATTO?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN
IF YOU HAVE NORMAL SKIN PLEASE PICK YOUR PREFERRED LIP TREATMENT *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
OMBRE LIP (SATURATION OF PIGMENT CLOSEST TO LIP LINE AND SOFT FADE AS IT GETS CLOSER TO INNER LIP)
NOT APPLICABLE
COMBINATION BROW
IF YOU HAVE OILY, COMBINATION, OR LARGE PORES: PLEASE PICK YOUR PREFRERED LIP *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
NOT APPLICABLE
IF YOU HAVE MATURE, SUN-DAMAGED, WRINKLED SKIN. PLEASE PICK YOUR BROW OPTION BELOW *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK
NOT APPLICABLE

WHAT DO I WANT MY LIPS TO LOOK LIKE? *

IF YOU HAVE PREVIOUS LIP TATTOO OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
Ninth Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
SKIN CONDITIONS: *
ECZEMA
PSORISIS
KERATOS PILARIS (rough patches and acne-like bumps)
DERMATITIS
ROSACEA
NONE
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL LIP APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
NONE OF THE ABOVE

WHAT LIP IS BEST FOR ME?

HAVE YOU HAD PREVIOUS PMU OR LIP TATTO?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN
IF YOU HAVE NORMAL SKIN PLEASE PICK YOUR PREFERRED LIP TREATMENT *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
OMBRE LIP (SATURATION OF PIGMENT CLOSEST TO LIP LINE AND SOFT FADE AS IT GETS CLOSER TO INNER LIP)
NOT APPLICABLE
COMBINATION BROW
IF YOU HAVE OILY, COMBINATION, OR LARGE PORES: PLEASE PICK YOUR PREFRERED LIP *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
NOT APPLICABLE
IF YOU HAVE MATURE, SUN-DAMAGED, WRINKLED SKIN. PLEASE PICK YOUR BROW OPTION BELOW *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK
NOT APPLICABLE

WHAT DO I WANT MY LIPS TO LOOK LIKE? *

IF YOU HAVE PREVIOUS LIP TATTOO OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
Tenth Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
SKIN CONDITIONS: *
ECZEMA
PSORISIS
KERATOS PILARIS (rough patches and acne-like bumps)
DERMATITIS
ROSACEA
NONE
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL LIP APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
NONE OF THE ABOVE

WHAT LIP IS BEST FOR ME?

HAVE YOU HAD PREVIOUS PMU OR LIP TATTO?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN
IF YOU HAVE NORMAL SKIN PLEASE PICK YOUR PREFERRED LIP TREATMENT *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
OMBRE LIP (SATURATION OF PIGMENT CLOSEST TO LIP LINE AND SOFT FADE AS IT GETS CLOSER TO INNER LIP)
NOT APPLICABLE
COMBINATION BROW
IF YOU HAVE OILY, COMBINATION, OR LARGE PORES: PLEASE PICK YOUR PREFRERED LIP *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
NOT APPLICABLE
IF YOU HAVE MATURE, SUN-DAMAGED, WRINKLED SKIN. PLEASE PICK YOUR BROW OPTION BELOW *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK
NOT APPLICABLE

WHAT DO I WANT MY LIPS TO LOOK LIKE? *

IF YOU HAVE PREVIOUS LIP TATTOO OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
SKIN CONDITIONS: *
ECZEMA
PSORISIS
KERATOS PILARIS (rough patches and acne-like bumps)
DERMATITIS
ROSACEA
NONE
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL LIP APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
NONE OF THE ABOVE

WHAT LIP IS BEST FOR ME?

HAVE YOU HAD PREVIOUS PMU OR LIP TATTO?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN
IF YOU HAVE NORMAL SKIN PLEASE PICK YOUR PREFERRED LIP TREATMENT *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
OMBRE LIP (SATURATION OF PIGMENT CLOSEST TO LIP LINE AND SOFT FADE AS IT GETS CLOSER TO INNER LIP)
NOT APPLICABLE
COMBINATION BROW
IF YOU HAVE OILY, COMBINATION, OR LARGE PORES: PLEASE PICK YOUR PREFRERED LIP *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK (HEALS AS LIGHT LIP STICK LOOK, MORE SATURATED WITH PIGMENT)
NOT APPLICABLE
IF YOU HAVE MATURE, SUN-DAMAGED, WRINKLED SKIN. PLEASE PICK YOUR BROW OPTION BELOW *
LIP BLUSH (HEALS AS LIGHT TINT ON LIPS)
LIP STICK
NOT APPLICABLE

WHAT DO I WANT MY LIPS TO LOOK LIKE? *

IF YOU HAVE PREVIOUS LIP TATTOO OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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