First Name *

Last Name *

Date of birth *

Gender in Birth *

Phone *

Email *

Emergency Contact Name *

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.

New Patient Intake Form