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Lit Aesthetics Event Intake Form

LIT Aesthetics Event Intake Form

We're thrilled we'll get to see you and help you feel your best soon! Please answer this intake form so we can have all our supplies ready to assist you! Should you have any questions please reach out to us via getlithealth.com

Name(Required)

First Last

Email(Required)

Phone(Required)

What is your date of birth?(Required)

Which event are you attending? (Please enter name and/or date of event).(Required)

What are your desired aesthetic goals? Help with (check all that apply):(Required)

Lip filler

Forehead

"Elevens"

Crows Feet

"Bunny Nose"

When was the last time you had toxin and/or fillers?(Required)

Do you know approximately how many units were used in your last appointment?

Do you have any pre-existing medical conditions? Be as exhaustive as you can. If you have a history of myasthenia gravis, ALS, Eaton-Lambert Syndrome, or any progressive muscle weakness disorder, please make that known.(Required)

Have you been on any antibiotics within 4 weeks from today? If so, which one(s)?(Required)

Are you currently taking any medications? If so, what are they? Specifically list any blood-thinners, anti-inflammatories, supplements such as acai berry, alfalfa, vitamins E and K, Advil, Aleve, aspirin, coumadin, steroids, Xarelto and Eliquis.

Do you have any allergies? List all known allergies if so.(Required)

How did you hear about us?

By submitting this form you agree that LIT Health may email you to confirm your registration and may add you to their newsletter (which you can opt out of at any time).(Required)

I agree

Name

This field is for validation purposes and should be left unchanged.

Lit Aesthetics Event Intake Form

LIT Aesthetics Event Intake Form

"Every individual deserves the opportunity to invest in their health and wellness."