Medical Waiver | Michel Design Studio

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MDS

Permanent Makeup Health Questionnaire

Michel Design Studio

Michel Hernandez

(License #1543)

First name

Last name *

Email

Date of Birth

Occupation

How did you hear about us?

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.

*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? *

No

Yes

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 *

No

Yes

Have you previously had a permanent makeup (PMU) procedure from a NON-MDS Artist? *

No

Yes

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? *

No

Yes

Have you received chemotherapy treatment within the past 6 months? *

No

Yes

Have you had Botox injection in the last 15 days? *

No

Yes

Are you currently on Accutane, or have you taken it within the last year? *

No

Yes

Do you use Retin-A, Glycolic Acid, Vitamin C or other exfoliants? *

No

Yes

Have you had a chemical peel? *

No

Yes

Do you tint your brows and/or lashes, or currently use eyelash enhancing products? *

No

Yes

Do you have collagen, Restalyine, Juvaderm, or fat transfers in any part of your face? *

No

Yes

Do you have a history of herpes infection (cold sores/fever blisters)? *

No

Yes

Have you had a herpes (cold sore/fever blister) infection within the last 21 days? *

No

Yes

Do you bruise or swell easily? *

No

Yes

Do you suffer from a medical skin condition such as keloids, hypertrophic scarring, psoriasis, or any current open wounds or lesions? *

No

Yes

History of skin disease, skin cancer, or skin lesions at the site of the service? *

No

Yes

Do you have a heart condition? If yes, is the condition being monitored or treated by a physician? *

No

Yes

Are you currently on steroids or anti-inflammatory medications? *

No

Yes

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? *

No

Yes

Do you have a history of hemophilia, excessive bleeding, or other blood/bleeding disorder? *

No

Yes

Do you have tattoos? If yes, did you heal normally after the procedure? *

No

Yes

Do you spend a lot of time in the sun and/or a chlorinated pool? *

No

Yes

Are you planning any cosmetic surgery in the near future? If yes, when and what type of procedure? *

No

Yes

Have you had or plan to have laser treatment? Please describe where/when on the body in the box below *

No

Yes

Have you consumed more than 8oz of alcohol within the past 24 hours or consumed food within the last 4 hours? *

No

Yes

Do you have other health considerations that could complicate this procedure or your healing? *

No

Yes

Do you have a history of epilepsy, seizures, fainting or narcolepsy? *

No

Yes

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)? *

No

Yes

History of eye disease, glaucoma disorder, or suffer from frequent eye infections? *

No

Yes

Are you currently under a physician’s care for any condition? *

No

Yes

Have you taken any medications in the past 6 months? *

No

Yes

Are you currently under the influence of drugs or any mind-altering chemicals? *

No

Yes

Feel free to add any additional information that you believe we should be informed about before moving forward with the procedure. You should consult a Physician prior to the procedure if you have any concerns related to any condition(s) listed or omitted on this form.

I hereby certify that all statements contained within this document have been
read, answered accurately, and are true to the best of knowledge.

Your Signature

Select a date

I declare that the info I’ve provided is accurate & complete

I refuse to disclose any & all personal medical information.

Thanks for submitting!

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Copyright © 2024 Michel Design Studio, LLC

342 Corder Rd. Suite A I Warner Robins, GA 31088

support@micheldesignstudio.com
478.297.7547

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