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Basic Medical Background

Please submit a basic medical background prior to your appointment to go paperless today!

Birthday
Month
Day
Year
Multi-line address
Are you pregnant or nursing?
Yes
No

*Cannot legally receive these services if nursing or pregnant in the State of Alaska

Have you had any blood thinners in the last 24 hours?
Yes
No

Blood thinners (including alcohol, supplements or medication such as Fish Oil or Aspirin) increase chances of bleeding during service, recomend abstain 48 hours ideally prior to service

Have you had any stimulants within the last 24 hours?
Yes
No

Stimulants (including caffeinated beverages or medications) increase chances of bleeding during service, recommend abstain 48 hours ideally prior to service

Do you use tobacco?
Yes
No

Tobacco use is stimulating and may slow healing

Are you sensitive or allergic to topical products such as hand cremes, body lotions or makeup?
Yes
No
Are you sensitive to metals, such as metals used in jewelry?
Yes
No
Do you have any allergies or sensitivities we should be aware of?
Yes
No

Please list allergies.

We have a no latex policy.

Are you allergic or resistant to over the counter level numbing products?
Yes
No
Have you ever had cold sores, fever blisters, or any type of herpes?
Yes
No

If concerned for breakouts, recommend taking Valtrex the same day as service

Have you experienced Hepatitis or Jaundice during the past 12 months?
Yes
No
Do you have a history of stroke or heart attack?
Yes
No
Do you have any seizure related conditions?
Yes
No
Do you have any heart conditions?
Yes
No
Do you have high or low blood pressure?
Yes
No
If you answered yes to the last question, which type?
High
Low
Are you wearing a pacemaker?
Yes
No
Do you have a history of skin sensitivities?
Yes
No
Do you bruise for no obvious reason?
Yes
No
Do you have any problems healing?
Yes
No
Are you Diabetic?
Yes
No
If you answered yes to the last question, which type?
Type 1
Type 2
Do you have any autoimmune disorders?
Yes
No
Do you have Arthritis
Yes
No
Do you faint or become dizzy?
Yes
No
Are you Anemic?
Yes
No
Are you under treatment for depression or other mood disorders?
Yes
No
Do you take prescription drugs?
Yes
No
Do you have sinus problems?
Yes
No
Do you personally have any history of Cancer?
Yes
No
Are you undergoing radiation or chemotherapy treatment?
Yes
No
Do you have glaucoma or any other eye disease?
Yes
No
Do you have any medical condition that has resulted in a medical professional requiring you to medicate with an antibiotic prior to a dental or other invasive procedure?
Yes
No
Do you have dry-eye?
Yes
No
Do you have prosthetic implants?
Yes
No
Do you wear contact lenses?
Yes
No
Do you menstruate?
Yes
No

If close to monthly cyclical cellular turnover (whether you menstruate or not) you may be more sensitive during service due to the natural stimulant released during this time.

Have you had Permanent Makeup or Tattoos done before?
Yes
No
If you have had Permanent Makeup or Tattoos done before, have you had any issues healing after they were applied?
Yes
No
Do you have any moles, skin tags or scarring in the area we'll be tattooing?
Yes
No
Do you hyper-pigment due to injury or skin damage?
Yes
No

Develop dark pigmentation over injured area

Do you hypo-pigment due to injury or skin damage?
Yes
No

Loss of pigment over injured area

Do you intentionally tan?
Yes
No

Direct sun or tanning bed tanning fades tattoos, especially exposed on the face

Do you scar easily from minor skin injuries?
Yes
No
Do you tend to develop keloid or hypertrophy scars?
Yes
No
Do you bleed excessively from minor cuts?
Yes
No
Do you routinely use chemically exfoliating products such as Accutane, Retin-A, Glycolic, etc...?
Yes
No

Use of exfoliating products must stop at least 2 weeks before and after tattooing. Use of Accutane must stop for 1 full year before tattooing, no exception.

Have you had a facial treatment in the last month?
Yes
No

Must wait at least 2 weeks before service in treated area, and 2 weeks to treat the tattooed area.

Have you had a laser treatment in the last 6 months?
Yes
No

Recommend waiting at least 1 month before service in treated area, and 1 month to treat the tattooed area depending on strength

Have you had a chemical peel within 6 months?
Yes
No

Must wait 1 month or longer after treatment before tattoing can be done, depending on strength. Recommend wait 1 month or longer after tattooing to get treatment done depending on strength.

Are your lips injected with any filler material?
Yes
No

Must wait 3 months after receiving filler before tattooing, wait 8 weeks to get filler after tattooing. Filler in face will depend on location.

Do you have Botox injections?
Yes
No

Must wait at least 2 weeks before any tattooing can be done, wait two weeks after tattooing to get Botox.

Do you have lash extensions?
Yes
No

Cannot tattoo any eyeliner with lash extensions, remove two weeks before tattooing, recommend to wait at least three weeks after tattooing to get lash extensions.

Do you use any lash serums?
Yes
No

Cannot tattoo over treatment area. Must stop serum application 6 weeks before and after tattooing.

Do you have any ongoing medical conditions treated or untreated that we should be aware of?
Yes
No
Is there anything else we should know that we haven't already asked?
Yes
No
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Date
Month
Day
Year

321 West 5th Avenue, Anchorage Alaska 99501

(907) 868-4678

MissShannonsPmu@Gmail.com

by appointment only

​

Tues - FrI: 10:15 pm - 6:00pm  

Saturday: 10:15pm - 6:00pm

Sunday/Monday closed

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