Lip Blushing Questionnaire
Sign in to Google to save your progress. Learn more
First and Last Name *
Phone Number *
Email Address *
Why are you interested in having your lips done? *
Do you have or have you had lip fillers/injections? *
If yes to fillers/injections, when was the last time?
MM
/
DD
/
YYYY
Have you ever had cold sores? *
If yes, when was the last time you had an outbreak(an approx date is okay)?
MM
/
DD
/
YYYY
Since you have had cold sores in the past, you will need to get a prescription for Valtrex to take 5 days before the service and 5 days after the service. Be sure to have at least 20-25 days worth of the prescription so there is enough for your touch-up appointment as well. Do you agree to adhere to this? *
Are you currently on medication for high blood pressure? *
Are you currently on blood thinning medication? *
List of all current medications you are taking: *
When were you looking to have this procedure done? *
Do you have any upcoming trips? *
If yes, what is the date of your trip?
MM
/
DD
/
YYYY
If maybe, when approximately do you think you'll be going?
MM
/
DD
/
YYYY
Preferred communication method: *
How did you find me/who referred you? *
Do you have any questions? If so, please list them below.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms