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MDS

Permanent Makeup Health Questionnaire

Michel Design Studio 

Michel Hernandez

(License #1543)

Description & location of Body Art Procedure:

PowderBrow is a PMU technique that’s used to create a softly shaded brow that enhances the clients’ natural facial features. The final result will appear soft & powdery. The location of the PMU work will be directly on the brow area.

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*A Copy of Clients Government-Issued ID will be required at time of procedure

Do Any of the Following Apply to you?

Please expand on any question answered 'yes' in the below most column.*

ANSWER EACH & EVERY QUESTION 
Yes or No
Are you currently pregnant and/or breastfeeding? Have you been pregnant within the last 3 months?
Do you have, or have you had a positive test for any of the following: Auto-immune disorder, Thyroid disorder, Hepatitis A, B, or C, HIV/AIDS, Jaundice-The health conditions listed may increase health risks associated with receiving a Body Art procedure
Have you previously had a permanent makeup (PMU) procedure from a NON-MDS Artist?
History of allergies, anapyhlactic reactions, or sensitivities to pigments, dyes, disinfectants, metals, latex, hair dye, lidocaine, paints, crayons, glycerin, cosmetics, or soaps? Any other known allergies?
Have you received chemotherapy treatment within the past 6 months?
Have you had Botox injection in the last 15 days?
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?
Do you tint your brows and/or lashes, or currently use eyelash enhancing products?
Do you have collagen, Restalyine, Juvaderm, or fat transfers in any part of your face?
Do you have a history of herpes infection (cold sores/fever blisters)?
Have you had a herpes (cold sore/fever blister) infection within the last 21 days?
Do you bruise or swell easily?
Do you suffer from a medical skin condition such as keloids, hypertrophic scarring, psoriasis, or any current open wounds or lesions?
History of skin disease, skin cancer, or skin lesions at the site of the service?
Do you have a heart condition? If yes, is the condition being monitored or treated by a physician?
Are you currently on steroids or anti-inflammatory medications?
Do you have diabetes medication that affects the neurological or immune system in fighting infection or other conditions which may affect blood circulation and/or ability to fight infection?
Do you have a history of hemophilia, excessive bleeding, or other blood/bleeding disorder?
Do you have tattoos? If yes, did you heal normally after the procedure?
Do you spend a lot of time in the sun and/or a chlorinated pool?
Are you planning any cosmetic surgery in the near future? If yes, when and what type of procedure?
Have you had or plan to have laser treatment? Please describe where/when on the body in the box below
Have you consumed more than 8oz of alcohol within the past 24 hours or consumed food within the last 4 hours?
Do you have other health considerations that could complicate this procedure or your healing?
Do you have a history of epilepsy, seizures, fainting or narcolepsy?
Currently using drugs or other treatments with anticoagulants (Arfarin, Xarelto, Plavix, Eliquis, etc.) or other medications that thin the blood and/or interfere with blood clotting (blood thinners)?
History of eye disease, glaucoma disorder, or suffer from frequent eye infections?
Are you currently under a physician’s care for any condition?
Have you taken any medications in the past 6 months?
Are you currently under the influence of drugs or any mind-altering chemicals?
Health Authority Contact Information

If you have any complaint, question, or concern regarding safety, sanitization, or sterilization procedures, you may contact:

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Macon-Bibb County Health Department
1600 Forsyth Street Macon, GA 31201

Phone: 478-746-0121

I hereby certify that all statements contained within this document have been read, answered accurately, and are true to the best of my knowledge. I also acknowledge that I am voluntarily obtaining services of my own free will and volition.

Thanks for submitting!

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