LIPS & BODY BY JESS

Comprehensive Aesthetic Clinical History Form

By reviewing and completing this online form, you acknowledge that you have read, understood, and agree to the terms outlined in the ‘Lips & Body By Jess; Comprehensive Aesthetic Clinical History Form.’ Your submission constitutes your informed consent to proceed in accordance with these terms.

Consent to treatment

I voluntarily consent to receive lip filler treatment at Lips & Body by Jess, acknowledging that I understand the procedure, its risks, possible side effects, and that results may vary.

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Company Policies

All appointments require a non-refundable deposit, timely arrival, full disclosure of health conditions, and acknowledgment that all sales are final and results may vary.

Booking & Deposit Policy

A $25 non-refundable deposit is required to secure your appointment.
This deposit will be applied toward your total on the day of service.
No-shows or late cancellations will result in forfeiture of the deposit.

Late Arrival Policy

A 10-minute grace period is allowed.
Clients arriving more than 10 minutes late may need to reschedule, and the deposit will be held.

Touch-Up Policy

Touch-up services are available within 1–3 months of your initial appointment.
If additional product is required, extra charges may apply.

Refund Policy

All deposits and services are non-refundable.
Results vary per individual and cannot be guaranteed.

Consultation & Medical Disclosure

Every service includes a consultation.
Clients must disclose all allergies, medical conditions, or relevant health history prior to treatment.

The provider reserves the right to decline service if you are not a suitable candidate.

I understand that:

Lip filler treatments involve the injection of hyaluronic acid or other FDA-approved dermal filler substances to enhance lip volume and shape.
Possible side effects include swelling, bruising, redness, tenderness, lumpiness, and in rare cases, infection, vascular occlusion, or allergic reactions.
Results vary by individual and are not guaranteed.
I will follow all pre- and post-care instructions provided by my practitioner.
I have disclosed all relevant medical information truthfully and completely.
The provider has explained the procedure, risks, and alternatives, and I have had the opportunity to ask questions to my satisfaction.

I voluntarily consent to receive lip filler treatment at Lips & Body by Jess.

Online Form

General Medical History and Background
History of Chronic Diseases and Specific Conditions
Please mark YES or NO and describe in detail if your answer is YES.

Declaration of Responsibility and Consent

I declare that all the information provided in this form is true, accurate, and complete to the best of my knowledge and belief.

I understand that the information I have provided is essential for the evaluation of my suitability for the requested treatments (Hyaluronic Acid Filler, Restylane, Hydralip, Juvederm, Lip Dissolving, Lipo Enzime, Stretch Marks & Stomach Tightening, Fibroblast Pen, Botox, Xeomin, or others).

I AGREE AND UNDERSTAND THAT ANY ADVERSE OUTCOME, COMPLICATION, OR DISSATISFACTION RESULTING FROM INCORRECT, INCOMPLETE, OR UNDISCLOSED MEDICAL, ALLERGY, OR BACKGROUND INFORMATION WILL BE MY SOLE RESPONSIBILITY, AND I EXPRESSLY RELEASE THE COMPANY AND THE PROFESSIONAL IN CHARGE OF ALL LIABILITY RELATED TO SUCH OMISSION OR MISREPRESENTATION.