Step 2: Read, agree & return our pre-client questionnaire 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 Pre-Client Questionnaire Your Name * Date * Your Email Address * Cell Phone * Type of Procedure you're requesting * 1. Have you ever had any permanent makeup in the past by another technician? * Yes No - If so, what area was tattooed, how many times and when was the last time? 2. Are you Pregnant, nursing, or trying to get pregnant? (No Exceptions) * Yes No 3. Any scars or experienced any head trauma in the brow area? * Yes No 4. Lazy eye? * Yes No 5. Blepharitis - Inflammation of the Eyelids or any other disorders affecting the eyelid area? * Yes No 6. 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 (No Exceptions) - Rapid swelling and bleeding is a complication from these products. Pigment does not retain. 7. Do you wear false lashes? They must be removed prior * Yes No 8. Heart Conditions/Pace Maker/Defibrillator (No exceptions) * Yes No 9. Alopecia - Hair loss due to auto immune disease? * Yes No Hair strokes will appear more blurred or blended if so. 10. Trichotillomania - Compulsive pulling of body hair? * Yes No 11. Shingles - Have you EVER had shingles on your face? * Yes No No exceptions...PMU will not be performed as the procedure could cause a flare up. 12. Eczema, Psoriasis, Chronic Reddened Area or Dermatitis in or around the brow area? * Yes No Constant flaking/itching/irritation/shedding of skin 13. Oily or severely oily skin? * Yes No The hair strokes will appear more blended, solid or not retain at all. 14. Large pores on your forehead & in the brow area? * Yes No Pigment will blur/blend in large pores looking powdered. 15. Hemophilia-Bleeding Disorder - a rare bleeding disorder in which the blood doesn’t clot normally? * Yes No 16. Menopause - Considered. * Yes No 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) 17. Does your body typically run hot, perspiring frequently? * Yes No 18. Platelet Disorders-Aggregation Disorders? * Yes No 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. 19. Moles/raised areas in or around the brow area? * Yes No Pigment will not be put into anything raised. No exceptions, even if it looks incomplete. 20. Piercing in the brow area - Scars can cause the pigment to migrate or blur? * Yes No 21. Deep wrinkles in the brow area? * Yes No The Hair Strokes will not lay properly in the creases, giving the brow an uneven look 22. Hair transplant for your eyebrows? * Yes No Pigment will not take in the scar tissue where the plugs were placed. 23. Thyroid condition and taking medication for this condition.? * Yes No 24. Hypo, Hyper Thyroidism, Graves Disease, Hashimotos? * Yes No 25. Rosacea - severe reddening of the face? * Yes No 26. 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 27. On Accutane - acne medicine within the last year? * Yes No 28. Auto Immune Disorder of any kind (MS, RA, Lupus or the like)? * Yes No Due to the medicines to treat these diseases, pigment will not retain. 29. List medicines currently taking including all vitamins. NO FISH OIL, ASPIRIN, VITAMIN E - ONE WEEK PRIOR 30. MRSA - (can be very contagious) Have you ever had it? * Yes No 31. Extremely Thin skin - Transparent or Translucent or very vascular * Yes No 32. Frequent Exercise - (5-7 days per week) * Yes No 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! 33. Tanning/Out in the sun * Yes No 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, Mary may not be able to work on you in the future. Addendum will be required 34. Do you currently have any visual blemishes, pimples or breakouts in or around the forehead and or cheek area? * Yes No 35. Have you ever had a cold sore or do you have a history of cold sores (on the outside) on your lips? * Yes No And you can always send a photo later if you don't have one at the moment - simply go to the next step (Step 3) where you can upload photos directly from the website. Or you can use the email address to send an email with an attachment. Additional Notes Of Importance You'd Like To Share With Us? After you have answered all of the questions above, please click the Submit button 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) Here is an example of a perfect image to help you Use this to send a photo Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 15MB You can send up to 4 photos - just click inside the box to add photos. Please click the "Send Your Questionnaire" button below. This sends your questionnaire to Carolyn. You will then be directed to the next page (step 3) where you can send additional photos. Send Your Questionnaire Please make sure you click the “Send Your Questionnaire” button. If you leave the page without sending, the form gets cancelled and anything you have entered will be lost.