About this template
A Lip Blushing Intake and Health History Form is an essential tool for permanent makeup artists, aesthetic clinics, and beauty salons offering semi-permanent lip tattooing. Before performing any lip blushing procedure, it is critical to screen clients for contraindications, skin conditions, allergies, and medical histories that could affect pigment retention or healing.
This comprehensive intake form collects vital client details, emergency contacts, detailed medical backgrounds—such as a history of cold sores, bleeding disorders, or current medications like blood thinners—and informed consent acknowledgments. By digitizing this paperwork into a Google Form, beauty professionals ensure that all necessary disclosures and liability agreements are documented prior to the appointment. Clients can easily complete the form on their smartphones before arriving at the studio, streamlining your consultation workflow and helping you deliver a safe, personalized, and professional service.
Key features
- Screen clients for medical contraindications and skin conditions instantly.
- Collect mandatory informed consent and procedure acknowledgments.
- Mobile-friendly format for easy completion on phones or tablets.
- Centralize all client health records and responses in Google Sheets.
- Eliminate messy clipboards and streamline your pre-procedure workflow.
Use cases
Pre-appointment screening for permanent makeup and lip tattoo clients.
Collecting liability waivers and informed consent in beauty salons.
Documenting client allergies to numbing agents and topical products.
Maintaining organized digital health history records for aesthetic st…
Maintaining organized digital health history records for aesthetic studios.
What this form collects
- Full Name (Short answer)Enter your first and last name as it appears on your government-issued ID.
- Email Address (Short answer)We will use this to send your appointment confirmation and aftercare instructions.
- Phone Number (Short answer)Enter your primary mobile number for appointment reminders.
- Date of Birth (Date)You must be 18 years or older to receive cosmetic tattooing services.
- Residential Address (Paragraph)Include your street address, city, state, and zip code.
- Occupation (Short answer)Optional — helps us understand your daily routine and healing environment.
- Are you currently pregnant or breastfeeding? (Multiple choice)Cosmetic tattooing is not performed during pregnancy or while breastfeeding.
- Do you have a history of fever blisters or cold sores (Herpes Simplex)? (Multiple choice)Lip tattooing can trigger outbreaks. Clients with a history of cold sores are typically required to take antiviral medication prior to the procedure.
- Check any medical conditions that apply to you: (Checkboxes)Select all active conditions or historical diagnoses.
- Are you currently taking any blood thinners or anticoagulants? (Multiple choice)Medications such as Aspirin, Ibuprofen, Warfarin, or high doses of Vitamin E can increase bleeding.
- Are you currently using Accutane, Retin-A, or strong exfoliants? (Multiple choice)Accutane must be completed at least 6 to 12 months prior to receiving cosmetic tattoos.
- List any known allergies (Paragraph)Include allergies to topical numbing agents (lidocaine, benzocaine), metals, latex, or specific pigments.
- List your current medications and supplements (Paragraph)Please list anything you take regularly.
- Procedure Eligibility and Understanding (Multiple choice)By checking below, you confirm that all medical history provided is accurate and truthful to the best of your knowledge.
- Client Signature (Short answer)Please type your full legal name as an electronic signature to confirm your consent.
- Signature Date (Date)Today's date.
FAQ
What is the main purpose of this lip blushing intake form?
It collects essential client health history, identifies potential contraindications like cold sores or blood thinners, and secures informed consent before a lip blushing procedure.
Who should use this intake template?
Permanent makeup artists, cosmetic tattoo specialists, aesthetic clinic owners, and salon professionals who offer lip blushing services.
Can I customize the questions to fit my specific salon policies?
Yes! Once you generate the form in Google Forms, you can fully edit, add, or remove any questions, policies, or brand details to suit your studio.
How do clients fill out this form before their appointment?
You can easily share the Google Form link via email, text message, or embed it directly on your booking website so clients complete it in advance.
Where is the client data stored?
All client submissions are securely stored in your Google Drive and automatically populated into a connected Google Sheet for easy organization.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.