Permanent Makeup Health Questionnaire
Kendra Neal Studio
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Email
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example@example.com
Occupation
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How did you hear about us?
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Do any of the following apply to you?
Please expand on any question answered 'yes' in the right most column.
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Rows
Yes
No
Description
Are you currently pregnant and/or breastfeeding, or, have you been pregnant in the last 3 months?
Do you have, or have you a positive test for any of the following?
Auto-immune disorder
Thyroid disorder
Hepatitis A, B or C
HIV/AIDS
Jaundice
If yes, please list any that apply in the column to the right:
Have you previously had a permanent makeup (PMU) procedure from a non-KNS artist in the area you are planning to receive PMU?
History of allergies, anaphylactic reactions, or sensitivities to: pigments, dyes, disinfectants, metals, latex, hair dye, lidocaine, glycerin, cosmetics, or soaps? Any other known allergies?
Have you received chemotherapy treatment within the past 6 months? If yes, enter date of final treatment in the column to the right.
Have you had Botox injection in the last 15 days? If yes, where were the injections (answer in the column to the right)?
Are you currently on Accutane, or have you taken it within the last year?
Do you use Retin-A, Glycolic Acid, Vitamin C or other exfoliants?
Have you had a chemical peel? If yes, list date of last treatment in the column to the right.
Do you tint your brows and/or lashes, or currently use eyelash enhancing products? If yes, please list products in the column to the right.
Do you have collagen, Restalyine, Juvaderm, or fat transfers in any part of your face? If yes, please describe in the column to the right.
Do you have a history of herpes infection (cold sores/fever blisters)?
Do you have a history of keloid formation or hypertrophic scarring? If yes, please describe in the column to the right.
Do you have history of skin disease, skin cancer, or skin lesions at the site of the service?
Are you currently on steroids or anti-inflammatory medications? If yes, please list in the column to the right.
Do you have diabetes or other conditions which may affect blood circulation and/or ability to fight infection? If yes, please describe in the column to the right.
Do you have a history of hemophilia, excessive bleeding, or other bleeding/clotting disorder?
Do you have tattoos? If yes, did you heal normally after the procedure? Please describe in the column to the right.
Do you spend a lot of time in the sun and/or a chlorinated pool? List any that apply in the column to the right.
Are you planning any cosmetic surgery in the near future? If yes, when and what type of procedure? Please answer in the column to the right.
Have you consumed more than 8oz of alcohol within the past 24 hours?
Do you have a history of epilepsy, seizures, fainting or narcolepsy?
Are you currently using drugs or other treatments with anticoagulants or other medications that thin the blood and/or interfere with blood clotting (such as aspirin, warfarin, Xarelto, Plavix, Eliquis, etc.)?
Are you currently under a physician’s care for any condition or do you have any other health considerations that could complicate this procedure or your healing? If yes, please describe in the column to the right.
Have you taken any medications in the past 6 months? If yes, please list in the column to the right.
Have you eaten in the last 4 hours?
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I understand and accept that any of the health conditions I disclosed above may increase the risks associated with receiving a body art or permanent makeup procedure, including the risk of infection, delayed healing, allergic reaction, or other complications.
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I certify that I have read and fully understood this health questionnaire, that all answers I have provided are accurate and complete to the best of my knowledge, and that I have not withheld any relevant medical information. I understand that withholding or providing false information may increase my risk of an adverse outcome and release Kendra Neal Studio, LLC from any liability arising from such omissions or inaccuracies
Signature
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Date
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