Pre-treatment Questionnaire Name * First Name Last Name Email Address * Your information will be kept confidential, stored securely, and used only to assess your suitability and safety for a semi-permanent make-up procedure. By completing this form, you consent to this. * I consent Date or birth * MM DD YYYY Emergency contact name * Emergency contact telephone number * (###) ### #### Do you wear contact lenses? * Yes No Are you allergic to any medications? * Yes No Do you have a sensitivity to latex? * Yes No Are you allergic to products with a petroleum base, antibiotic ointment, or lidocaine products? * Yes No Are you allergic to any metal? * Yes No Are you allergic to red food dyes, hair colours, glues or adhesives? * Yes No Are you currently taking any anticoagulant (blood thinning) medications? (i.e.: Aspirin, Ibuprofen or Warfarin) * Yes No Have you received any cortisone medications or steroids in the past 6 weeks? * Yes No Do you have any problems healing? * Yes No Have you undergone chemotherapy or radiation in the last 6 months? * Yes No Have you ever had cold sores, fever blisters, canker sores or herpes? * Yes No Do you have any history of skin diseases or particular skin sensitivities? * Yes No Have you had laser or a chemical peel in the last 6 weeks? * Yes No Are you using AHA’s or Retin-A? * Yes No Are you presently pregnant or breast feeding? * Yes No Do you have any eye disorders? * Yes No Do you have any other medical issues not listed above? * Yes No If you have answered YES to any of the questions above, please provide additional information regarding your medical issue. Have you ever had any previous permanent makeup procedures? * How did you hear about the Anastasiya Studio? Do you give your consent to photos and videos taken on the day of your procedure to be shared on social media? * Yes No Do you give your consent for The Anastasiya Studio to contact you with exclusive offers and events (via email / text)? * Yes No I confirm that the above information provided is correct and can confirm that I am over the age of 18. * Yes No By answering YES, I am happy to have the procedure explained in full on the day of my appointment. * Yes No By answering YES and booking your appointment your agreeing to the terms and conditions published and set by The Anastasiya Studio. Full aftercare instructions will be provided on the day of your appointment. * Yes No To be completed by your artist. Treatment area, pigment mix, needle type and device (any other notes) To be completed by your artist. Treatment area, pigment mix, needle type and device (any other notes) Thank you for completing your pre-treatment questionnaire, and we look forward to welcoming you to The Anastasiya Studio
