Date
First Name
Middle Name
Last Name
Birth Date
Email Address *
Mobile Number *
Address (City) *
State *
Country *
Health Declaration Please understand that this treatment is not for everyone. In order to find out if you are fit for this procedure, please answer the following health questions truthfully. Linda Paradis Group will assume no liability in the event you give false information to obtain the treatment.
Have you done Botox or Filler in last 4 weeks?
Have you done Botox or Filler in last 4 weeks? *
Yes
No
Are you Allergic to Sesame Seeds ?
Are you Allergic to Sesame Seeds ? *
Yes
No
Please list any medical conditions, issues, or medications not listed above
In order to ensure the health and safety of our staff and clients, please answer the following questions truthfully and to the best of your knowledge. Your responses will be kept confidential.
How many removal sessions done before? *
Tattoo Description and History
Please submit a picture of your Tattoo
Please submit a picture of your ID/Passport
I understand that there are certain inherent risks associated with this Detox Lips Snow lips procedure and I assume full responsibility for all personal injury to myself as a result of this procedure, and I further realize that negligence in any case may result in any injury, loss or damage arising out of this procedure, whether caused by fault of myself. I understand that if I have any unexpected problems with the healing of my skin, I should contact a doctor immediately. I had an opportunity to ask any and all questions about any of my concerns regarding the procedure and the terms of this consent with attachments. All of my questions and concerns have all been addressed to my satisfaction and I enter into this consent upon my own free will and accord without and any questions or reservations, whatsoever, about the procedure and the terms of the consent and attachments contained herein.
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