the micropigment studio

medical questionnaire

BEFORE YOU BEGIN

REVIEW IMPORTANT INFORMATION

Once your consultation is complete and your treatment plan has been established, you’re ready to schedule your procedure. A non-refundable deposit is required to reserve your appointment time and secure your treatment date.

Prior to booking, your health history must be reviewed to determine whether physician clearance is necessary for any major medical conditions. If you have questions before booking, please call or text (831) 251-7229, or schedule a consultation online, by phone, Zoom, or in person.

Financing options are available, and SMP payment arrangements may be discussed during your consultation.

Appointment Policies

Review important information regarding appointments, deposits, cancellations, rescheduling, and treatment guidelines.

SMP Pre & Post Care Instructions

Learn how to prepare for your scalp micropigmentation procedure and properly care for your scalp during the healing process.

Permanent Makeup Pre & Post Care Instructions

Review preparation and aftercare instructions for brows, eyeliner, lip blush, and other permanent makeup procedures.

MEDICAL QUESTIONNAIRE

COMPLETE YOUR HEALTH HISTORY FORM

Please complete the questionnaire below as accurately as possible. Your health history helps determine whether treatment is appropriate and whether physician clearance may be required before proceeding.

All information provided is kept confidential and used solely for treatment planning and safety purposes.

MEDICAL HISTORY QUESTIONNAIRE

Name

First Last

Date

Phone

Emergency Contact

First Last

Phone

Have you had any cosmetic surgery during the last year?(Required)

Yes

Have you had any cosmetic injectables or fillers in the face within the last month?(Required)

Yes

Have you had prior SMP by another technician?

If you have, please provide date, and country of provider.

Have you ever had hair transplants?(Required)

If yes, approximate date and name of surgeon.

If having SMP, have you used any hair serums or hair growth products on your scalp in the last 3 months?(Required)

If yes, please list product name and approximate dates.

Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol?(Required)

Yes

Do you use any medications that might affect the healing of the body art you wish to receive?(Required)

Yes

Do you have any other medical or skin conditions that affect the outcome of your procedure?(Required)

Yes

Do you have a history of herpes at the procedure site?(Required)

Yes

Do you have any other medical or skin conditions that affect the outcome of your procedure?(Required)

Yes

Have you ever been prescribed antibiotics prior to dental or surgical procedures?(Required)

Yes

Do you have any cardiac valve disease?(Required)

Yes

Is there any information you feel you should provide to the body art practitioner?(Required)

Yes

Other medical conditions?(Required)

Yes

Please check any conditions listed below that apply to you.

I have read and understand the policies and information regarding pre-post care procedures.(Required)

Yes

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