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the micropigment studio

Medical Questionnaire

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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.

    Appointment Policies

  • SMP Pre & Post Care Instructions

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

    SMP Pre & Post Care Instructions

  • Permanent Makeup Pre & Post Care Instructions

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

    Permanent Makeup Pre & Post Care Instructions

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.

Name
Emergency Contact
Have you had any cosmetic surgery during the last year?
Have you had any cosmetic injectables or fillers in the face within the last month?
Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol?
Do you use any medications that might affect the healing of the body art you wish to receive?
Do you have any other medical or skin conditions that affect the outcome of your procedure?
Do you have a history of herpes at the procedure site?
Do you have any other medical or skin conditions that affect the outcome of your procedure?
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
Is there any information you feel you should provide to the body art practitioner?
Other medical conditions?
Please check any conditions listed below that apply to you.
I have read and understand the policies and information regarding pre-post care procedures.

The Micropigment Studio, santa clara

580 El Camino Real, Suite 3Santa Clara, California 95050

Email

jmicropigment@gmail.com

Call Us

(831) 251-7229

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