Patch Test Consent/Waiver Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Do you have any existing allergies? *

Please list: *

Are you currently (or possibly may be) pregnant or breastfeeding? *

Do you have any medical conditions? *

Please list: *

Have you previously experienced a reaction to dye / tint / treatment / product ? *

Please specify: *

Consent

While allergies to treatments are unusual, it is always possible to have a reaction in regards to any new treatment we undertake. Please read the following statements carefully.

Please tick each statement to show your understanding and agreement: *

I confirm that I have disclosed all relevant information to my therapist I confirm I have had all potential side effects/reactions explained to me in regards to this treatment

Please select: *

I am having my patch test today and I understand that even though only a small area is treated there is a possibility there may be a reaction within this area and I am choosing to go ahead with this treatment taking all benefits and potential side effects into consideration I am consenting to having my treatment today without having a patch test. I understand why they are recommended but I have decided that I knowingly and voluntarily waive this skin patch test for today. I acknowledge that a patch test is available at any time as per my request

Client Name, Signature and Date: *

Tap or click on the signature above to sign

Patch Test Results - Therapist to complete

Date patch test was applied:

Did the client experience a reaction to the patch test?

Please give detail:

Is the treatment still going ahead?

Therapist Signature: *

Set a reminder: