Questionnaire

Have you ever had a cosmetic tattoo/microblading in the area of the face where you are requesting a service (even if the pigment has already faded)? Please submit your pictures to pmbyainura@gmail.com first. Your pictures will need to be approved first!

No

Yes

Are you 18 years old or older?

No

Yes

Are you currently pregnant, nursing, harvesting eggs, or trying to get pregnant?

No

Yes

Are you prone to keloids?

No

Yes

Do you have Eczema, Psoriasis, or Dermatitis in or around the tattoo area (Constant flaking/itching/irritation/shedding of skin)?

No

Yes

Have you been taking Accutane (acne medicine) within the last 12 months?

No

Yes

Do you have Hemophilia-Bleeding Disorder?

No

Yes

Do you have any Heart Conditions/Pace Maker/Defibrillator?

No

Yes

Do you have any scars, piercings or experienced any trauma in the tattoo area? If you do, please attach a clear picture at the bottom of the form

No

Yes

Do you take any of these medications? * Prasugrel (Effient) // Triflusal (Disgren) // Clopidogrel (Plavix) // Ticagrelor (Brilinta) // Ticlopidine (Ticlid) // Cilostazol (Pletal) // Vorapaxar (Zontivity) // Dipyridamole (Persantine) // Coumadin // Pradaxia (dibigatran) // Xarelto (rivaraxaban) // Eliquis (apixaban) // Savaysa (edoxaban)

No

Yes

Have you EVER had Shingles on your face before? Even if it was years ago

No

Yes

Do you suffer from Trichotillomania (Compulsive pulling of body hair)?

No

Yes

Do you have any Platelet Disorders? (When platelets do not bind with fibrinogen and other proteins in order to stick to other platelets. As a result, the platelets cannot form a plug to stop the bleeding from a damaged blood vessel

No

Yes

Do you have any moles/raised areas/pimples in or around the tattoo area? If you do, please attach a close up picture

No

Yes

Do you have any deep wrinkles in the tattoo area? If you do, please add a close up photo

No

Yes

If you are scheduling an eyebrow appointment. Have you had a hair transplant procedure for your eyebrows in the past?

No

Yes

Do you have any of the Thyroid conditions? (Hypo/Hyper Thyroidism – pigment might not retain or may fade faster. No additional touch-ups will be performed earlier than 12 months from the last service to avoid skin trauma if it happens).

No

Yes

Do you have an active Cancer of any kind or if you had chemotherapy/radiation within the last 6 months?

No

Yes

Do you have Rosacea (diagnosed severe reddening of the face)?

No

Yes

Do you have MRSA (can be very contagious)?

No

Yes

Do you have extremely thin skin (Transparent or Translucent or very vascular)? Due to hypersensitivity, this type of skin does not take the pigment well

No

Yes

Do you exercise frequently (5-7 days/week)? Due to the frequent sweating (salt), pigment MIGHT NOT retain, fade faster or change color. No additional touch-ups will be performed earlier than 12 months after the last service to avoid trauma if it happens.

No

Yes

If you are scheduling a lip service. Have you ever had cold sores on your lips before (even if it was only once or years ago)? If you did, you will need to get a prescription for an antiviral medication from your physician to prevent a possible outbreak.

No

Yes

Do you have an Auto-Immune Disorder of any kind (Multiple sclerosis, Rheumatoid arthritis, Lupus, Type 1 Diabetes, Graves Disease, Hashimoto’s Thyroidism, etc)? You MUST bring a note from your doctor giving consent for the procedure.

No

Yes

Are you a Fitzpatrick type I or II (natural redhead/blonde/very light skin/eyes)? Due to hypersensitivity, this skin type does not take the pigment well. No additional touch-ups will be performed earlier than 12 months to avoid skin trauma if it happens

No

Yes

Do you smoke daily? Smoking will make the pigment fade faster and change color overtime

No

Yes

By scheduling an appointment with us, you are agreeing that you have read and fully understand the information listed on our "Policies" page at https://www.bestpermanentmakeupdmv.com/policies & don't have any contraindications for the procedure *

No

Yes