SECTION A – Personal & Contact Info

First Name *

Last Name *

Date of birth *

Gender in Birth *

Address

Street Address *

City *

State *

Country *

Postal Code *

Phone *

OK to contact you by phone calls/voicemail? *

Yes

No

OK to contact you by SMS? *

Yes

No

Email *

OK to contact you by Email? *

Yes

No

Occupation *

Marital Status *

Ethnicity *

We ask about ethnicity as part of our scientific approach to personalized care. Different ethnicities have unique genetic skin characteristics, which can affect how the skin responds to certain treatments and products. By understanding this, we can reduce the risk of complications like hyperpigmentation and ensure you receive the safest and most effective treatment.

SECTION B – Emergency Contact

Emergency Contact Name *

Relationship to You

Emergency Contact Phone *

SECTION C – Main Concerns & Goals

What are your main concerns? *

Multi-select

If “Other” or anything you want to explain, tell us more

What are your top 3 goals for your skin / body / wellness? *

SECTION D – Treatments You’re Interested In

Which treatments would you like to hear more about? *

Multi-select

Anything specific you’re curious or worried about?

SECTION E – Medical Safety (Core Health Flags)

Are you currently pregnant or trying to become pregnant? *

Yes

No

Are you currently breastfeeding? *

Yes

No

Have you delivered a child in the last 6 months? *

Yes

No

Do you have diabetes (Type 1, Type 2 or gestational)? *

Yes

No

Do you have a history of high blood pressure or heart problems? *

Yes

No

Do you have a personal history of any cancer? *

Yes

No

Do you currently have any kind of cancer? *

Yes

No

Do you have any autoimmune conditions? *

Yes

No

(examples: rheumatoid arthritis, psoriasis, lupus, etc.)

Do you have any blood or clotting issues, or take blood thinners? *

Yes

No

Do you have liver (hepatic) disease or hepatitis? *

Yes

No

Do you have kidney disease or kidney function problems? *

Yes

No

Do you have any neurologic conditions? *

Yes

No

(examples: seizures, stroke, multiple sclerosis, epilepsy, etc.)

Do you have HIV or AIDS? *

Yes

No

Do you have any mental health diagnoses we should be aware of? *

Yes

No

Do you have any abdominal issues? *

Yes

No

(examples: hernia, bariatric surgery, other major abdominal surgery)

Do you have any medical implants? *

Yes

No

Do you have any metal implants *

Yes

No

(examples: plates, screws, joint replacements, etc.)

Do you have a pacemaker? *

Yes

No

Do you have a history of cold-related conditions? *

Yes

No

(examples: Raynaud’s, cold urticaria/hives, cryoglobulinemia, etc.)

Do you have any numbness or loss of sensation in the areas you want treated? *

Yes

No

Are you currently experiencing any other illness or medical issue not mentioned above? *

Yes

No

If you answered “Yes” to any medical questions, please give details here: *

SECTION F – Medications, Allergies & Lifestyle

Do you currently take any medications or supplements? *

Yes

No

Please list your current medications / supplements:

Do you have any allergies? *

Yes

No

(examples: food, medications, latex, iodine, skincare, tape, etc.)

If yes, list your allergies:

Have you ever had a bad reaction or complication from cosmetic treatments? *

Yes

No

(injectables, laser, chemical peels, facials, devices, etc.)

If yes, please describe:

Do you smoke or vape nicotine? *

Yes

No

Do you use recreational / illegal drugs? *

Yes

No

On most days, do you drink at least ~2 liters (half a gallon) of water? *

Yes

No

SECTION G – Previous Aesthetic Treatments

Have you had any previous treatments on your FACE? *

Yes

No

(laser, peels, microneedling, RF, exosomes, etc.)

If yes, please describe:

Have you had any previous treatments on your BODY? *

Yes

No

(liposuction, fat freezing, cavitation, RF, EMS, etc.)

If yes, please describe:

Do you currently have any fillers or neuromodulators? *

Yes

No

(Botox, Xeomin, Jeuveau, etc.)

If yes, where and roughly when were they done?

SECTION H – Legal, Policies & Consents

Privacy Notice & Use of Medical Information *

I have read and agree to the Privacy Practices.

All sales are final. Dr. Lift does not offer refunds on services, packages, memberships, deposits, or products under any circumstances. Unused or unredeemed services are non-refundable. Deposits are non-refundable and forfeited if cancellation or rescheduling occurs within 24 hours. Chargebacks or payment disputes are not permitted and constitute a breach of our Terms & Conditions.

General Treatment Consent & Acknowledgment of Risks *

I have read and agree to the General Treatment Consent & Acknowledgment of Risks.

By proceeding with treatment at Dr. Lift Spa, you confirm that services are voluntary, medical information provided is accurate, and results are not guaranteed. You acknowledge and accept all associated risks and release Dr. Lift Spa and its staff from liability related to outcomes or dissatisfaction. All services, products, packages, and deposits are final and non-refundable, and chargebacks are not permitted. By continuing, you agree to Dr. Lift Spa’s Privacy Practices and Terms & Conditions at drliftspa.com/terms-conditions.

Full Name *

Date of Signature *

Signature *

Clear

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

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