Patch Test Consent Form

Patch Testing is a procedure for testing a customer's skin for any allergic reaction from a substance that is going to be used for the procedure that he or she desires to undergo. It involves placing a few drops or a small amount of the substance on the skin, leaving it for 48 hours for observation for potential reaction or effects which may include rashes, infection, or any skin irritation. Patch Testing is one of the classic methods for checking with a client if he or she has any allergic reaction to any of the creams or skin applications that shall be used on him/her. This way, we can safely proceed with the procedure if no allergic reaction happens after 48 hours. Although a patch test is made, however, this is not a guarantee that the client will not have any further allergic reaction.

I hereby declare that I was recommended to undergo a patch test. It was explained to me the risks involved should I choose not to go with the patch test prior the procedure. I have had the opportunity to ask questions as well as relevant information regarding the patch test was explained to me to my satisfaction. I understand that I must notify the technician in case any adverse effects happen after the treatment in order to receive proper instructions on the next measures to take. I understand that in the case of an adverse reaction to my skin, I shall not hold The Beauty Room or my technician responsible.

I wish to undergo a patch test prior the treatment.I do not wish to undergo a patch test. I take full responsibility and all the risk involved should any adverse reaction happens during or after treatment.

Name*

First NameLast Name

Phone Number

Please enter a valid phone number.

Email*

example@example.com

Therapist Signature *

Parent/guardian signature If client is under 18.

Clients Signature*