Membership Treatment Planner

Membership Treatment Plan Form

We value your membership at Dr. Lift Spa and strive to make managing your account as simple and convenient as possible. Please use this form to request a membership pause or cancellation.

Member Verification Details

Phone *

Email *

Concerns *

Multiple options

Fitzpatrick Skin Type *

PIGMENTATION

[Plan – Pigmentation] Primary pigmentation type

Multiple options

[Plan – Pigmentation] Additional pigmentation types

Multiple options

[Plan – Pigmentation] Overall severity

[Plan – Pigmentation] Areas affected

Multiple options

[Plan – Pigmentation] Visible pattern

Multiple options

[Plan – Pigmentation] Suspected pigment depth

[Plan – Pigmentation] Is the underlying condition still active?

Yes

Uncertain

[Plan – Pigmentation] Known or likely triggers

Multiple options

[Plan – Pigmentation] Duration

[Plan – Pigmentation] Still becoming darker or spreading?

Yes

Uncertain

[Plan – Pigmentation] Skin currently irritated or barrier-impaired?

Yes

[Plan – Pigmentation] History of dark marks after irritation or procedures?

Yes

Uncertain

[Plan – Pigmentation] Current pigment-directed treatments

Multiple options

[Plan – Pigmentation] Current sunscreen use

[Plan – Pigmentation] Melasma-associated triggers

Multiple options

[Plan – Pigmentation] Dermatology evaluation indicators

Multiple options

[Plan – Pigmentation] Duration of consistent pigment-control regimen

[Plan – Pigmentation] Response to pigment-control regimen

[Plan – Pigmentation] Acne scars or textural irregularities also present?

Yes

⚠️ Active or contributing acne was identified. Add ACNE and complete the Acne section.

⚠️ Acne scarring or meaningful texture was identified. Add ACNE SCARRING and complete the Acne Scarring section.

⚠️ An inflammatory or dermatitis-related contributor was identified. Add REDNESS and complete the Redness section.

ACNE

[Plan – Acne] Active lesion types

Multiple options

[Plan – Acne] Overall acne severity

[Plan – Acne] Breakout areas

Multiple options

[Plan – Acne] Breakout pattern

Multiple options

[Plan – Acne] Duration of current acne problem

[Plan – Acne] Has acne caused permanent scarring?

Yes

Uncertain

[Plan – Acne] Persistent dark marks after acne?

Yes

[Plan – Acne] Persistent red or pink marks after acne?

Yes

[Plan – Acne] Is a hormonal contribution suspected?

Yes

Uncertain

[Plan – Acne] Known or suspected aggravating factors

Multiple options

[Plan – Acne] Current acne-directed treatments

Multiple options

[Plan – Acne] Duration of current acne regimen

[Plan – Acne] Response to current acne regimen

[Plan – Acne] Skin significantly irritated or barrier-impaired?

Yes

[Plan – Acne] Does the patient pick or manipulate lesions?

Yes

[Plan – Acne] Does the presentation appear consistent with acne vulgaris?

Yes

Uncertain / possible acne mimic

No / likely another condition

[Plan – Acne] Treatment goals

Multiple options

⚠️ Persistent post-acne dark marks were identified. Add PIGMENTATION and complete the Pigmentation section.

⚠️ Permanent structural acne scarring was identified. Add ACNE SCARRING and complete the Acne Scarring section.

⚠️ Persistent red or pink post-acne marks were identified. Add REDNESS and complete the Redness section.

ACNE SCARRING

Note: flat brown or red marks are not structural acne scars.

[Plan – Acne Scarring] Scar types present

Multiple options

[Plan – Acne Scarring] Dominant treatment concern

[Plan – Acne Scarring] Active inflammatory acne still present?

[Plan – Acne Scarring] Do rolling scars appear tethered or anchored?

Yes

Uncertain

[Plan – Acne Scarring] Predominant boxcar-scar depth

Shallow

Moderate

Deep

Mixed depths

Uncertain

[Plan – Acne Scarring] Extent of ice-pick scars

[Plan – Acne Scarring] Overall structural severity

[Plan – Acne Scarring] Areas affected

Multiple options

[Plan – Acne Scarring] Brown or dark post-acne marks also present?

Yes

[Plan – Acne Scarring] Red or pink post-acne marks also present?

Yes

[Plan – Acne Scarring] Prolonged darkening after irritation or procedures?

Yes

Uncertain

[Plan – Acne Scarring] History of keloids or abnormal raised scarring?

Yes

Uncertain

[Plan – Acne Scarring] Treatment area irritated or barrier-impaired?

Yes

[Plan – Acne Scarring] Previous acne-scar treatments

Multiple options

[Plan – Acne Scarring] Response to previous treatment

[Plan – Acne Scarring] Acceptable treatment downtime

[Plan – Acne Scarring] Primary treatment goal

⚠️ Persistent red or pink post-acne marks were identified. Add REDNESS and complete the Redness section.

⚠️ Active acne remains present. Add ACNE and complete the Acne section.

⚠️ Brown or dark post-acne marks were identified. Add PIGMENTATION and complete the Pigmentation section.

REDNESS

Note: Continue only if clinically meaningful redness present.

[Plan – Redness] Primary redness presentation

[Plan – Redness] Additional redness presentations

Multiple options

[Plan – Redness] Overall severity

Mild

Moderate

Severe

[Plan – Redness] Areas affected

Multiple options

[Plan – Redness] How does the redness behave over time?

[Plan – Redness] Recurrent flushing

[Plan – Redness] Visible superficial vessels or telangiectasias present?

[Plan – Redness] Rosacea-pattern papules or pustules

[Plan – Redness] Are acne-type blackheads or whiteheads also present?

Yes

[Plan – Redness] Associated symptoms

Multiple options

[Plan – Redness] Is the skin barrier visibly impaired or significantly irritated?

Yes

Uncertain

[Plan – Redness] Does the presentation appear consistent with active dermatitis or another inflammatory rash?

Yes

Uncertain

[Plan – Redness] Did the red marks develop after acne lesions resolved?

Yes

Uncertain

[Plan – Redness] Does the presentation support a rosacea pattern?

Yes

Uncertain

[Plan – Redness] Redness and flushing triggers

Multiple options

[Plan – Redness] Duration

[Plan – Redness] Is the redness progressively worsening or spreading?

Yes

Uncertain

[Plan – Redness] Current redness treatments

Multiple options

[Plan – Redness] Treatment response

[Plan – Redness] Symptoms suggestive of ocular rosacea

Multiple options

[Plan – Redness] Phymatous changes or progressive skin thickening present?

Yes

Uncertain

[Plan – Redness] Atypical findings requiring further evaluation

Multiple options

⚠️ Acne or an acne-related contributor was identified. Add ACNE and complete the Acne section.

SKIN QUALITY

[Plan – Skin Quality] Primary concern

[Plan – Skin Quality] Additional concerns

Multiple options

[Plan – Skin Quality] Overall severity

[Plan – Skin Quality] Areas affected

Multiple options

[Plan – Skin Quality] Characterize the texture problem

[Plan – Skin Quality] Superficial fine lines

[Plan – Skin Quality] Enlarged pores

[Plan – Skin Quality] Pore visibility driver

[Plan – Skin Quality] Are true blackheads or whiteheads present?

Yes

Uncertain

[Plan – Skin Quality] Oil/sebum level

[Plan – Skin Quality] True dry skin

[Plan – Skin Quality] Dehydration

[Plan – Skin Quality] Is the skin barrier impaired or significantly irritated?

Yes

Uncertain

[Plan – Skin Quality] Low radiance/dullness

[Plan – Skin Quality] Is meaningful redness, burning, or sensitivity also present?

Yes

Uncertain

[Plan – Skin Quality] Crepey texture

[Plan – Skin Quality] Loss of firmness

[Plan – Skin Quality] Visible signs of photoaging

Multiple options

[Plan – Skin Quality] Current active skincare

Multiple options

[Plan – Skin Quality] Moisturizer/barrier support

[Plan – Skin Quality] Sunscreen use

[Plan – Skin Quality] Previous treatments

Multiple options

[Plan – Skin Quality] Previous treatment response

[Plan – Skin Quality] Acceptable downtime

[Plan – Skin Quality] Primary goal

⚠️ Acne or an acne-related contributor was identified. Add ACNE and complete the Acne section.

⚠️ Meaningful pigmentation or mottled photodamage was identified. Add PIGMENTATION and complete the Pigmentation section.

⚠️ Established lines or structural laxity were identified. Add FACIAL AGING and complete the Facial Aging section.

⚠️ Barrier impairment with meaningful redness or sensitivity was identified. Add REDNESS and complete the Redness section.

FACIAL AGING

[Plan – Facial Aging] Primary facial-aging concern

[Plan – Facial Aging] Areas of concern

Multiple options

[Plan – Facial Aging] Overall degree of aging or structural change

[Plan – Facial Aging] Dynamic forehead lines

[Plan – Facial Aging] Dynamic glabellar/frown lines

[Plan – Facial Aging] Dynamic crow’s-feet lines

[Plan – Facial Aging] Significant lines visible at rest

[Plan – Facial Aging] Midface volume/support loss

[Plan – Facial Aging] Where is midface support loss most apparent?

Multiple options

[Plan – Facial Aging] Nasolabial folds

[Plan – Facial Aging] Marionette lines

[Plan – Facial Aging] Chin projection/contour deficiency

[Plan – Facial Aging] Loss of jawline definition

[Plan – Facial Aging] Jowling/tissue descent

[Plan – Facial Aging] Facial skin or soft-tissue laxity

[Plan – Facial Aging] Under-eye concern type

Multiple options

[Plan – Facial Aging] Under-eye hollowing

[Plan – Facial Aging] Meaningful under-eye or malar edema/festooning present?

Yes

Uncertain

[Plan – Facial Aging] Are lower-eyelid bags or fat prolapse a major component?

Yes

Uncertain

[Plan – Facial Aging] Under-eye skin quality

[Plan – Facial Aging] Hydration or crepey skin-quality concern

[Plan – Facial Aging] Dullness/reduced radiance

[Plan – Facial Aging] Submental fat

[Plan – Facial Aging] Submental/neck laxity

[Plan – Facial Aging] Previous facial injectables

Multiple options

[Plan – Facial Aging] Current filler concerns

Multiple options

[Plan – Facial Aging] Open to injectables

Yes

Unsure

[Plan – Facial Aging] Is tissue descent too substantial for the stated goal to be achieved nonsurgically?

Yes

Uncertain

⚠️ A meaningful skin-quality component was identified. Add SKIN QUALITY and complete the Skin Quality section.

⚠️ Pigment-related under-eye darkness was identified. Add PIGMENTATION and complete the Pigmentation section.

⚠️ A vascular or redness-related under-eye component was identified. Add REDNESS and complete the Redness section.

BODY CONTOURING

[Plan – Body Contouring] Primary body concern

[Plan – Body Contouring] Additional body concerns

Multiple options

[Plan – Body Contouring] Treatment areas

Multiple options

[Plan – Body Contouring] Overall severity

[Plan – Body Contouring] Localized subcutaneous fat in target area

[Plan – Body Contouring] Fat/fullness character

[Plan – Body Contouring] Fat distribution

[Plan – Body Contouring] Current weight trend

[Plan – Body Contouring] Is significant overall weight loss a main goal?

Yes

Uncertain

[Plan – Body Contouring] Skin/soft-tissue laxity

[Plan – Body Contouring] Laxity pattern

[Plan – Body Contouring] Cellulite severity

[Plan – Body Contouring] Cellulite pattern

[Plan – Body Contouring] Muscle-tone goal

[Plan – Body Contouring] Current muscle definition

[Plan – Body Contouring] Fluid retention/puffiness

[Plan – Body Contouring] Fluid/swelling pattern

Multiple options

[Plan – Body Contouring] Previous body-contouring treatments

Multiple options

[Plan – Body Contouring] Previous treatment response

[Plan – Body Contouring] Expected improvement

[Plan – Body Contouring] Primary body-contouring goals

Multiple options

[Plan – Body Contouring] Do you have a history of cold-related conditions?

Yes

[Plan – Body Contouring] Do you have any abdominal issues (e.g. hernia)?

Yes

PELVIC FLOOR

[Plan – Pelvic Floor] Primary concern

[Plan – Pelvic Floor] Leakage with coughing, sneezing, exercise, or physical effort

[Plan – Pelvic Floor] Sudden difficult-to-defer urinary urgency

[Plan – Pelvic Floor] Leakage with a strong sudden urge

[Plan – Pelvic Floor] Urinary frequency

Yes

Uncertain

[Plan – Pelvic Floor] Times usually waking at night to urinate

[Plan – Pelvic Floor] Overall severity

Mild

Moderate

Severe

[Plan – Pelvic Floor] Impact on daily life

[Plan – Pelvic Floor] Pad or protective-garment use

[Plan – Pelvic Floor] Symptom duration

[Plan – Pelvic Floor] Is the concern related to pregnancy or childbirth?

[Plan – Pelvic Floor] Supervised pelvic-floor muscle training history

[Plan – Pelvic Floor] Muscle-training response

[Plan – Pelvic Floor] Structured bladder-training history

[Plan – Pelvic Floor] Can the patient identify and contract the pelvic-floor muscles correctly?

[Plan – Pelvic Floor] Prolapse symptoms

Multiple options

[Plan – Pelvic Floor] Pelvic, vaginal, bladder, or unexplained lower abdominal pain present?

Yes

Uncertain

[Plan – Pelvic Floor] Retention or bladder-emptying symptoms

Multiple options

[Plan – Pelvic Floor] Possible UTI symptoms

Multiple options

[Plan – Pelvic Floor] Unexplained blood in urine

Yes

Uncertain

[Plan – Pelvic Floor] Previous pelvic-floor treatments

Multiple options

[Plan – Pelvic Floor] Previous treatment response

[Plan – Pelvic Floor] Primary goals

Multiple options

HAIR LOSS

[Plan – Hair Loss] Primary hair/scalp concerns

Multiple options

[Plan – Hair Loss] When did the hair loss or shedding begin?

[Plan – Hair Loss] Overall course

[Plan – Hair Loss] Distribution/pattern

Multiple options

[Plan – Hair Loss] Increased shedding

[Plan – Hair Loss] Patterned miniaturization or caliber variation present?

[Plan – Hair Loss] Follicular openings

[Plan – Hair Loss] Significant broken hairs present?

Yes

Uncertain

[Plan – Hair Loss] Scalp symptoms

Multiple options

[Plan – Hair Loss] Scarring/inflammatory alopecia indicators

Multiple options

[Plan – Hair Loss] Potential trigger within the months before onset

Multiple options

[Plan – Hair Loss] Traction/high-tension styling

[Plan – Hair Loss] Repetitive pulling, picking, twisting, or manipulation suspected?

Yes

Uncertain

[Plan – Hair Loss] Active scalp disorder

Multiple options

[Plan – Hair Loss] Relevant medical factors

Multiple options

[Plan – Hair Loss] Possible medication contribution

[Plan – Hair Loss] Hair-loss evaluation/labs

Multiple options

[Plan – Hair Loss] Current or previous treatments

Multiple options

[Plan – Hair Loss] Treatment response

[Plan – Hair Loss] Treatment goals

Multiple options

[Plan – Hair Loss] Provider impression

BODY PIGMENTATION

[Plan – Body Pigmentation] Primary presentation

[Plan – Body Pigmentation] Additional presentations

Multiple options

[Plan – Body Pigmentation] Areas affected

Multiple options

[Plan – Body Pigmentation] Overall severity

[Plan – Body Pigmentation] Visible pattern

Multiple options

[Plan – Body Pigmentation] Suspected pigment depth

[Plan – Body Pigmentation] Duration

[Plan – Body Pigmentation] Still becoming darker or spreading?

Yes

Uncertain

[Plan – Body Pigmentation] Known or suspected triggers

Multiple options

[Plan – Body Pigmentation] Is the condition causing the pigmentation still active?

Yes

Uncertain

[Plan – Body Pigmentation] Is friction, rubbing, pressure, or occlusion contributing?

Yes

Uncertain

[Plan – Body Pigmentation] Are bumps, ingrown hairs, acne, or folliculitis present?

[Plan – Body Pigmentation] Is the affected skin irritated or barrier-impaired?

Yes

Uncertain

[Plan – Body Pigmentation] Prolonged darkening after irritation, injury, or procedures?

Yes

Uncertain

[Plan – Body Pigmentation] Current pigment treatment

Multiple options

[Plan – Body Pigmentation] Sun exposure and sunscreen

[Plan – Body Pigmentation] Duration of consistent pigment and trigger-control regimen

[Plan – Body Pigmentation] Foundation response

[Plan – Body Pigmentation] Is roughness, scarring, or textural irregularity also present?

[Plan – Body Pigmentation] Previous procedures

Multiple options

[Plan – Body Pigmentation] Previous procedural response

[Plan – Body Pigmentation] Findings requiring medical or dermatology evaluation

Multiple options

[Plan – Body Pigmentation] Primary goals

Multiple options

⚠️ Body acne, folliculitis or follicular inflammation was identified. Add ACNE and complete the Acne section.

PREVENTATIVE SKIN

[Plan – Preventative Skin] Primary preventative goals

Multiple options

[Plan – Preventative Skin] How much corrective treatment does the skin require?

[Plan – Preventative Skin] Current texture

[Plan – Preventative Skin] Hydration status

[Plan – Preventative Skin] Early fine lines

[Plan – Preventative Skin] Firmness/collagen concern

[Plan – Preventative Skin] Congestion/pore maintenance

[Plan – Preventative Skin] Are true comedones or meaningful acne lesions present?

Yes

Uncertain

[Plan – Preventative Skin] Early photodamage

[Plan – Preventative Skin] Facial pigmentation

[Plan – Preventative Skin] Is the skin irritated or barrier impaired?

Yes

[Plan – Preventative Skin] Meaningful redness, burning, flushing, or sensitivity present?

Yes

Uncertain

[Plan – Preventative Skin] Current home-care routine

[Plan – Preventative Skin] Current retinoid use

[Plan – Preventative Skin] Daily photoprotection

[Plan – Preventative Skin] Appropriate or desired in-office treatment intensity

[Plan – Preventative Skin] Long-term goals

Multiple options

⚠️ Clinically meaningful acne-type congestion was identified. Add ACNE and complete the Acne section.

⚠️ Meaningful pigmentation or photodamage was identified. Add PIGMENTATION and complete the Pigmentation section.

⚠️ Corrective skin-quality needs were identified. Add SKIN QUALITY and complete the Skin Quality section.

⚠️ Established fine lines or structural aging were identified. Add FACIAL AGING and complete the Facial Aging section.

⚠️ Barrier impairment with redness or sensitivity was identified. Add REDNESS and complete the Redness section.

NECK / DECOLLETE

[Plan – Neck/Décolleté] Primary concern

[Plan – Neck/Décolleté] Additional concerns

Multiple options

[Plan – Neck/Décolleté] Overall severity

[Plan – Neck/Décolleté] Skin texture

[Plan – Neck/Décolleté] Texture depth

[Plan – Neck/Décolleté] Degree of fine or horizontal neck lines

[Plan – Neck/Décolleté] Crepey skin

[Plan – Neck/Décolleté] Skin laxity

[Plan – Neck/Décolleté] Photodamage

[Plan – Neck/Décolleté] Pigmentation

[Plan – Neck/Décolleté] Redness/vascular change

[Plan – Neck/Décolleté] Dryness/dehydration

[Plan – Neck/Décolleté] Is the treatment area irritated or barrier-impaired?

Yes

Uncertain

[Plan – Neck/Décolleté] Prolonged pigmentation after irritation or procedures?

Yes

Uncertain

[Plan – Neck/Décolleté] Findings requiring medical or dermatology evaluation

Multiple options

[Plan – Neck/Décolleté] Current active skincare

Multiple options

[Plan – Neck/Décolleté] Photoprotection

[Plan – Neck/Décolleté] Previous treatments

Multiple options

[Plan – Neck/Décolleté] Previous treatment response

[Plan – Neck/Décolleté] Open to injectable skin-quality treatment

[Plan – Neck/Décolleté] Acceptable downtime

[Plan – Neck/Décolleté] Treatment goals

Multiple options

[Plan – Neck/Décolleté] Is the neck or décolleté skin looseness too significant for nonsurgical skin-quality treatments alone to meet the patient’s goal?

Yes

Uncertain

⚠️ Barrier impairment with redness or sensitivity was identified. Add REDNESS and complete the Redness section.

⚠️ Meaningful pigmentation or photodamage was identified. Add PIGMENTATION and complete the Pigmentation section.

⚠️ Established fine lines or structural aging were identified. Add FACIAL AGING and complete the Facial Aging section.

⚠️ Corrective skin-quality needs were identified. Add SKIN QUALITY and complete the Skin Quality section.

⚠️ recurring preventative-maintenance goal was identified. Add PREVENTATIVE SKIN and complete the Preventative Skin section.

Treatment Timing, Priorities & Budget

Use this section to decide which concerns should begin first and whether the plan should prioritize speed, monthly affordability, or sequential treatment.

[Plan – Shared] Treatment scheduling preference *

[Plan – Shared] Concerns to start now

[Plan – Shared] Priority 1 concern *

[Plan – Shared] Priority 2 concern

[Plan – Shared] Priority 3 concern

[Plan – Shared] Maximum additional treatment budget per month

Enter the maximum amount the patient prefers to spend each month on treatments beyond the one included membership session. Enter 0 if no additional paid treatments are wanted.

[Plan – Shared] Maximum additional paid sessions per month

[Plan – Shared] How should the monthly budget be applied?

SHARED TREATMENT SAFETY CONFIRMATION

Please confirm that the following medical information is current before creating the treatment plan.

[Plan – Shared] Are you currently pregnant or trying to become pregnant? *

Yes

[Plan – Shared] Are you currently breastfeeding? *

Yes

[Plan – Shared] Do you have any neurologic conditions? *

Yes

[Plan – Shared] Do you have any medical implants? *

Yes

[Plan – Shared] Do you have any metal implants *

Yes

[Plan – Shared] Do you have a pacemaker? *

Yes

[Plan – Shared] Where is the active or suspected dermatitis/inflammatory rash located?

Choose one or more options