Name *

First Name

Last Name

Phone *

(###)

###

####

Are you prone to Keloid scarring? *

Yes

No

Do you use a retin-a/retinol? *

Yes

No

Do you have eczema or dermatitis in or around your lips? *

Yes

No

Are you pregnant or nursing? *

Yes

No

Do you have a Autoimmune disorder? *

Yes

No

Have you had cancer? *

Yes

No

Do you have allergies *

Yes

No

Have you had Lip filler? *

Yes

No

Have you ever had a cold sore?

Yes

No

Do you have any vacations planned within the next couple of months? *

Yes

No