Pre-Client Questionnaire

Step 2: Read, agree & return our pre-client questionnaire & Appointment Policy

Fill in the questionnaire below
Tick each of the boxes to confirm your agreement
Click the “Send Your Questionnaire” button

Clicking the button sends your questionnaire to Carolyn. You will then be directed to the next page (step 3) where you can send additional photos.

Pre-Client Questionnaire 2022

Your Name *

Date *

Your Email Address *

Cell Phone *

1. Type of Procedure(s) you are requesting. Click all that apply. *

(See description and prices under the PRICES TAB)

Eyebrows:

Powdered Brows

Ombre

Strokes Over Ombre

Hair-stroke Brows (I have read “Are You A Candidate For The Hair-Stroke Brows”?)

Unsure, but am happy to discuss this at the time of our appointment. I just know that I want the procedure done.

Eyes:

Eyelash Enhancement

Smudgy Eyelash Enhancement

Dramatic Eyeliner

Whisper Eyeliner

Lower Eyeliner Only

Unsure, but am happy to discuss this at the time of our appointment. I just know that I want the procedure done.

Lips:

Gloss and Go Lips

Luxo Lips

Unsure, but am happy to discuss this at the time of our appointment. I just know that I want the procedure done.

3. Are you a returning client of Carolyn Elliott Permanent Makeup, Inc? If so, you continue to the calendar to schedule. *

Yes

- And, if so, how long ago was your last visit, or last Permanent Makeup session?

4. Have you ever had any permanent makeup in the past by another technician? *

Yes

- If so, what area was tattooed, how many times and when was the last time?

5. Have you ever had Micro-blading completed to your eyebrows?

Yes

If so, what is the name of the person who did the work, and were you happy with the results?

6. Are you Pregnant? *

Yes

7. Do you have any scars or experienced any head trauma in the brow area? *

Yes

8. Lazy eye? *

Yes

9. Blepharitis - Inflammation of the Eyelids or any other disorders affecting the eyelid area? *

Yes

10. Do you use Lash Growth Products? You will need to be off an entire month, before and after any Eye Procedures. *

Yes, I accept this

(No Exceptions) - Rapid swelling and bleeding is a complication from these products. Pigment does not retain.

11. Do you wear false lashes? They must be removed prior *

Yes

12. Heart Conditions/Pace Maker/Defibrillator (No exceptions) *

Yes

13. Alopecia - Hair loss due to auto immune disease? *

Yes

Hair strokes will appear more blurred or blended if so.

14. Trichotillomania - Compulsive pulling of body hair? *

Yes

15. Shingles - Have you EVER had shingles on your face? *

Yes

No exceptions...PMU will not be performed as the procedure could cause a flare up.

16. Eczema, Psoriasis, Chronic Reddened Area or Dermatitis in or around the brow area? *

Yes

17. Oily or severely oily skin? *

Yes

18. Large pores on your forehead & in the brow area? *

Yes

19. Hemophilia-Bleeding Disorder - a rare bleeding disorder in which the blood doesn’t clot normally? *

Yes

20. Are you taking any blood thinners such as aspirin, fish oil, vitamin E, Coumadin daily? *

Yes

If so, are you able to be off of these blood thinners safely, with your physicians knowledge, 5 days before your procedure? *

Yes

(Not taking any blood thinners)

21. Menopause - Considered. *

Yes

If you have hot flashes during the procedure, the pigment will not retain and the procedure may have to stop. (You will be required to sign and addendum prior to procedure)

22. Does your body typically run hot, perspiring frequently? *

Yes

23. Platelet Disorders-Aggregation Disorders? *

Yes

An aggregation disorder is 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.

24. Moles/raised areas in or around the brow area? *

Yes

Pigment will not be put into anything raised. No exceptions, even if it looks incomplete.

25. Piercing in the brow area - Scars can cause the pigment to migrate or blur? *

Yes

26. Deep wrinkles in the brow area? *

Yes

The Hair Strokes will not lay properly in the creases, giving the brow an uneven look

27. Hair transplant for your eyebrows? *

Yes

Pigment will not take in the scar tissue where the plugs were placed.

28. Thyroid condition and taking medication for this condition.? *

Yes

29. Hypo, Hyper Thyroidism, Graves Disease, Hashimotos? *

Yes

30. Rosacea - severe reddening of the face? *

Yes

31. There are 6 skin types. Choose the one which best describes your skin type in the winter? *

Type I always burns, never tans

Type II usually burns, tans minimally

Type III sometimes mild burn, tans uniformly

Type IV burns minimally, always tans well

Type V very rarely burns, tans very easily

Type VI never burns, always tans

32. On Accutane - acne medicine within the last year? *

Yes

33. Auto Immune Disorder of any kind (MS, RA, Lupus or the like)? *

Yes

Due to the medicines to treat these diseases, pigment will not retain.

34. List medicines currently taking including all vitamins.

NO FISH OIL, ASPIRIN, VITAMIN E - ONE WEEK PRIOR

35. MRSA - (can be very contagious) Have you ever had it? *

Yes

36. Extremely Thin skin - Transparent or Translucent or very vascular *

Yes

37. Frequent Exercise - (5-7 days per week) *

Yes

Due to the frequent production of sweat(salt), the pigment WILL NOT retain, WILL fade very quickly, appear blurred or change in color. THIS WILL HAPPEN!

38. Tanning/Out in the sun *

Yes

Tanning, the results will fade quickly, heal darker, fade super fast or not retain at all. If you ruin the results by going out in the sun too soon, Carolyn will not be able to work on you in the future.

39. Do you currently have any visual blemishes, pimples or breakouts in or around the forehead and or cheek area? *

Yes

40. Have you ever had a cold sore or do you have a history of cold sores (on the outside) on your lips? *

Yes

41. Have you read our Appointment Policy document and agree to all its terms? *

Yes

You can download & view a copy of the appointment policy for later reference.

Download here and KEEP THIS FOR YOUR FOLLOW UP PROCEDURE!

42. I have read the Step One - “My Online Consultation” prior to the submission of this form. *

Yes, I have read the “My Online Consultation and feel fully informed.

No, I have not read this.

Do you have a Smart Phone? Simply take a "Passport Photo" similar image of your full-face and send it via Text to 805-550-7379. Be sure to include your full name with this text. Lastly, another method of sending a photo is to send it as an attachment to my email:
carolyn@carolyn-elliott.com.

Additional Notes Of Importance You'd Like To Share With Us?

After you have answered all of the questions above, please click the Send Your Questionnaire" button below to send your completed questionnaire.
We will evaluate your questionnaire, along with your photo before scheduling an appointment. Thank you.

Use this to send a photo of your face (without makeup, natural light, a solid background and a white shirt)

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Use this to send a photo

Maximum file size: 15MB

You can send up to 4 photos - just click inside the box to add photos.

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This sends your questionnaire to Carolyn. You will then be directed to the next page (step 3) where you can send additional photos.

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