Pre-procedure PMU Questionnaire
Thank you for choosing Moonwake! Please complete the following form to the best of your abilities before your booking is made. It won’t take long. ♡
Personal Information
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Previous Permanent Makeup
Please leave blank if not applicable.
Have you had a previous PMU procedure on the area you wish for me to work on?
Yes
No
If yes, how long ago was it done?
Please Select
Under 1 month ago
2-6 months ago
6-12 months ago
1-3 years ago
4+ years ago
Skin Condition
How would you best describe your skin type? Select all that apply.
*
Dry
Extremely dry
Oily
Combination
Balanced / normal
Mature
Youthful
Acne prone
Rosacea / psoriasis / eczema prone
Have you had any of the following treatments in the area of the desired PMU in the last 2 weeks?
*
Dermal fillers
Micro- needling
Chemical peels
Laser treatments
Are you currently on or have you been on isotretinoin in the last 6 months (roaccutane, accutane, isotane, etc.)?
*
Yes
No
Are any of the following in your current skin care routine? Select all that apply.
*
AHAs
Retinoids
None of the above
Medical Checklist
Please specify if you suffer from any allergies (seasonal, medication, food, cosmetics, anaesthetics, latex, menthol, petroleum, etc.)
*
Please specify if you are on any chronic medication. If yes, please provide the name.
*
Please select any of the options below that are applicable to you.
*
Currently pregnant
Breast feeding
Undergoing chemo therapy
None of the above
Procedure Questions
What procedure are you looking to get done?
*
Lip blush
Nano brows
Ombré / powder brows
Eyeliner
Corrective eyeliner
Corrective brow
Corrective lip / neutralisation
If you are receiving a procedure over existing pmu / looking to get a corrective procedure done, please attach a clear photo of the area with good natural lighting.
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Thank you for completing our client form!
Well done on completing the first step in your new journey. Please note: you will be contacted shortly to confirm your selected appointment date and time. A non-refundable booking deposit of 25% your procedure cost is required but will be deducted from your final pricing. ♡
Any questions, queries or concerns? I will get back to you as soon as possible.
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