Patch Test Consent Forms

Patch Test Consent Form
Although an allergy is unusual, there is always a possibility of an unknown allergy to the pigments and materials used during this procedure. In order to determine if you are allergic to anything that is used, a patch test is recommended prior to the initial procedure. If you wish, you can schedule an appointment with a medical professional to have the results professionally reviewed. If you choose to have a patch test, please sign the form below
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone#*
Email*
example@example.com
Please read and initial following:*

I confirm the reactions and sensitives have been fully explained to me.I accept that there may be a risk of an adverse reaction to this treatment, including the possibility of swelling, irritation, and redness.I understand that in the case of a reaction, I will not hold my therapist/technician responsible in any way, this includes any of the reactions specified above and/or any other reaction I may have.I understand that a negative patch test is not a guarantee that I will not experience a reaction. I understand that reactions and allergies can occur at any time even if I have had this treatment previously
Treatment for Patch Test:
Area Tested for Patch Test:
Notes:

Patch Test Consent Form