PMU PRE-QUALIFICATION SURVEY

I need a little bit of information to see if you are a good candidate for Cosmetic Tattoo services. By filling out this quick survey, this helps me ensure you are eligible for Permanent Makeup. The health, safety, and well-being of my clients is my top priority.

Are you ready to get started? *

I'M READY! LET'S DO THIS

Do you happen to be pregnant or currently breastfeeding? *

Yes

Are you diabetic? *

Yes

Ok, is your diabetes currently well controlled? *

Yes, it is.

No, it's not.

Do you have keloids or hypertrophic scars? *

Yes

Please provide a clear photo (in good lighting) of the area(s) to review. *

Upload your photo here...

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

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Do you have any autoimmune disorders or are you immunocompromised in any way? *

Yes

Please explain in detail below. Also, keep in mind, depending on the situation you may need a Doctor’s release form.

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Are you a smoker? *

Yes

Do you have existing permanent makeup? *

Yes

Please provide a clear photo of existing Permanent Makeup work.

Upload photo here...

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

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How long ago did you have your permanent makeup done? *

1 year

2 years

3 years

4 years

5+ years

Have you ever been on Accutane? *

Yes

Ok, when did you use Accutane last?

In the past 1 - 6 months

Longer than 6 months ago

Are you currently taking blood thinners? *

Yes

What kind of blood thinners are you currently taking? *

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Do you have any health or skin conditions? *

Yes

Please explain any health or skin conditions?

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Are you on any medications OTC or prescribed? *

Yes

What medications, how much, what for?

Full Name *

Email *

Phone *

Questions or Comments?