Pre-Treatment Screening Questionnaire

Pre-Treatment Screening Questionnaire
Client Name

First NameLast Name
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?

Other
Referred by/Other:
Please name the person who referred you, or how you heard of these services if you chose "Other"

Section I Preclusions

Rows	Yes	No
1. Is it possible you may be pregnant? or are you currently breast-feeding?
2. Are you prone to keloid scarring, hypertrophic scarring, or any other form of excessive scarring condition?
3. Have you taken a medication containing Isotretinoin (E.G.: Roaccutane) during the previous 12 months?
4. Have you been using any experimental, unapproved, or illegal medications or skin treatments?
5. Have you ever had any Microblading or type of permanent makeup done? If so, please detail below when it was done and where on your body the Microblading and/or permanent makeup was performed.
6. If you have permanent makeup or tattoos, did you have any problems with healing after the procedure was performed?
7. Are you over the age of 18?
8. Do you scar easily from minor skin injuries?

Please provide a detailed explanation if any of the above questions in Section I were marked "yes"

Section II Medical / Side Effects Questions

Rows	Yes	No
9. Do you have, or do you think it is possible you may have a Blood Borne Communicable Disease? E.G.: Hepatitis C Virus (HBC), Hepatitis B Virus (HBC), Human Immunodeficiency Virus (HIV)
10. Do you currently have any other form of communicable disease, or infection? E.G.: COVID, respiratory infection, gastrointestinal infection, skin infection, ear or eye infection, bacterial, fungal or viral infection etc. (If yes, please specify)
11. Do you have Diabetes, currently on any form of immunosuppressant therapy, or have any other condition that may cause delayed healing? (If yes, please specify)
12. Have you ever had cold sores/fever blisters?
13. Have you ever had or been treated for MRSA? (If yes, please specify)
14. Do you have any Hypersensitivity, Auto-Immune Disorder, or Allergic Conditions? (If yes, please specify)
15. Do you have a known allergy or sensitivity to lidocaine or any topical or local anesthetics/numbing including dental anesthetics?
16. Do you have any form of bleeding disorder, or are you taking any anticoagulants (blood thinners)? Anticoagulants include medications such as aspirin, warfarin, heparin and some anti-inflammatories (ibuprofen). In normal health and with low doses most supplements should not cause excessive bleeding but high doses (mega) of some supplements may interfere with normal blood clotting particularly; Omega 3 fatty Acids (Fish Oil/Flaxseed Oil), Vitamin E, Vitamin C, Coenzyme Q-10, Ginseng, Ginkgo Biloba, Garlic, Saw Palmetto and Glucosamine.
17. Have you had any form of Radiotherapy, or Chemotherapy at any time during the past 6 months? And/Or Have you ever had breast implant or joint replacement surgery? (If yes, please specify) This includes but is not limited to things such as cosmetic or reconstructive surgery, cancer treatments.
18. Do you suffer from any form of hyper or hypo pigmentary skin condition or rosacea? These are conditions that may result in increased or lack of pigmentation of the skin after minor skin trauma and include conditions such as Melasma, Post Inflammatory Hyper-Pigmentation (PIH), and inflammatory skin conditions with associated hyper-pigmentation. If you have scars or blemishes where the surrounding skin has become darker in color this may indicate the presence of a hyper-pigmentary skin condition. If in doubt answer yes to this question.
19. Have you ever taken a medication containing Isotretinoin (E.G. Roaccutane) Note: Answer yes to this question even if it was more than 12 months ago.
20. Have you had a laser or chemical peel within the last 6 months?
21. Have your lips been injected with filler materials? (If yes, please specify below when this was last done).
22. Do you bruise easily for no obvious reason?
23. Do you routinely use Retin-A, glycolic or other exfoliating products?
24. Do you have any problems healing?
25. Is your skin oily?

Please provide a detailed explanation if any of the above questions in Section II were marked "yes"

Acknowledgement, Waiver and Acceptance
I have read and understood the questions above. I am not under the influence of any drug(s), alcohol, or any other substance that has impaired my judgement or otherwise prohibits me from making sound, reasonable, and rational decisions. I hereby acknowledge that all of the information that I have provided is truthful and correct. I assume all responsibility to seek medical approval for the microblading/tattoo/Permanent Makeup procedure that I am requesting and hold below named Microblading Artist/Tattoo Artist/Permanent Make Up Artist (referred to herein as “Artist”) harmless from any and all claims, damages, or legal actions arising from or connected in any way with the procedure I am requesting be performed. I understand that the final outcome and healing of this service will be impacted by my strict adherence to aftercare directions given. I also understand that there may be factors outside of what was discussed with my Artist that may impact the healing process and final result of my procedure.

This questionnaire should only be regarded as a general guide and is not intended to replace medical advice or pretreatment health screening. Always consult with your medical practitioner before acting on any information in relation to any medical condition or health related circumstance. Your use of this form is strictly on the basis of your acceptance of the above terms and conditions.

I understand that on the day of my procedure if my Artist, at her sole discretion, determines that pre-procedure instructions have not been strictly followed or other relevant information that could impact the success of the procedure has not been given, my Artist may cancel, post-pone, or refuse to perform services and the procedure will be required to be paid in full.
Procedure to be performed on:
Client Name

First NameLast Name
Client Signature
Date signed by Client

YearMonthDay
Date
Artist Name: Rachel A. Ciriaco
Date Signed by Artist

MonthDayYear
Date
Use this box for Artist Notes
Artist Signature
Should be Empty:

Rows	Yes	No
26. Do you suffer with fainting, blackouts, seizures or migraines?
27. Do you have a cardiac pacemaker, Implanted Cardioverter Defibrillator (ICD), have a serious heart condition, or abnormal blood pressure?
28. Are you currently suffering from an emotional upset, major depression or other psychiatric illness? Note: Answer yes to this question if you feel that currently your judgment may be impaired for any reason.
29. Do you have any form of acute or chronic eye condition? (Glaucoma or any other eye disease).
30. Do you suffer with any other major health problems or medical conditions and/or are you taking any other regular or temporary medications/antibiotics? (If yes, please specify and list medications below).
31. Do you have high or low blood pressure, on blood pressure medication, or on an aspirin regimen?
32. Do you take NSAID’s on a regular basis?
33. Do you take any of the following: Mineral oil, Omega-3 Fish oil, Vitamin K, Gingko Biloba, Nattokinase, Serrapeptase, Vitamin E (therapeutic dosage/high dosage) (If yes, please list)
34. Are you anemic or have low iron?
35. Do you take iron supplements or receive iron infusions?
36. Do you suffer from low protein?
37. Do you have regular exposure to the sun? Excessive exposure in the last 2 weeks? (sun bathing, tanning beds, sunburn, irritation caused by sun exposure) (If yes, please specify)
38. Have you received Botox above the neck in the last month? (If yes, please specify what areas)
39. Do you have dry eyes?
40. Do you have a history of stroke or heart attack?
41. Do you have autoimmune disorders? (If yes, please specify below).
42. Do you menstruate?
43. Do you scar easily from minor skin injuries?
44. Do you bleed excessively from minor cuts?
45. Are you under treatment for depression?
46. Do you have or have ever been diagnosed with any type of herpes?
47. Do you have any type of hepatitis?
48. Do you have sinus problems?
49. Do you have any medical conditions that have resulted in a medical professional requiring you to pre-medicate with an antibiotic prior to dental or other invasive procedures?

Rows	Yes	No
50. Have you or any member of your household suffered with any form of skin infection in the previous 12 months? (If yes, please specify)
51. Do you have an allergy or sensitivity to latex/rubber?
52. Do you have a known allergy or sensitivity to any ingredients within tattoo pigments or needles, makeup, any preservatives, hair dyes, or other dyes? E.G.: glycerin, isopropyl alcohol, ethanol alcohol, iron oxides, titanium oxide, other metal oxides, nickel, witch hazel, carbon, etc. (If yes, please specify).
53. Do you have a known allergy or sensitivity to any ingredients in tattoo aftercare creams, antiseptics, lanoline, or petrolatum-based products?
54. Do you wear contact lenses?
56. Are you currently on hormone therapy or taking hormone medications?
57. Are you allergic or sensitive to any metals? E.G.: Metals used for jewelry?
58. Are you sensitive or allergic to hand creams or body lotions?
59. Do you have a history of skin sensitivities?

Pre-Treatment Screening Questionnaire

Acknowledgement, Waiver and Acceptance