CLOSE AESTHETICS PMU Consultation and Patch Test Form

PMU Consultation & Patch Test Form

This form is designed to provide you with information on patch testing and to complete a consultation in order to understand your goals and expectations from the procedure.
Section 1 - Patch Test
What is a patch test?

A Patch Test is a precautionary procedure which is performed to determine the reaction of your skin when a certain substance comes in contact with it. Your skin can show an allergic reaction such as inflammation, redness, itchiness, blisters, or a rash. This is called contact dermatitis.

Why do we patch test?

A patch test is a safety procedure to ensure that a person is not allergic to any of the pigments, makeup products or anaesthetic used. Additionally, it also helps the artist and the client to choose a colour or a combination of colours that would produce the best results.

When do we do a patch test?

A patch test needs to be completed at least 48 hours before the procedure.

How do we patch test?

We will agree and inconspicuous area to perform the patch test. This area will be cleaned using alcohol.

A topical or prick patch test will be conducted and a small amount of the pigment, anaesthetic, makeup will be placed on the skin or on the puncture site of the prick test.

If a reaction is observed, it might not be possble to perform a PMU a procedure.

Should you choose not to undergo a patch test you will take full responsibility and all the risk should any adverse reaction happen during or after the treatment.
Patch Test Outcome

Positive - red, itchy, irritated, swelling, painful and or pustules.Negative – no change to the skin.
Comments
Section 2 - The Consultation
This is where we collect information around your goals, discuss colour options and observe your skin. All of this will be recorded in the consultation form.
What procedure(s) are you interested in having?

EyebrowsEyelinerLipsOther
What are you hoping to achieve from this procedure?
Skin type

OilyDryCombinationNormalSensitiveAcneMature
Fitzpatrick scale

Type I (scores 0–6) always burns, never tans (palest; freckles)Type II (scores 7–13) usually burns, tans minimally (light coloured but darker than fair)Type III (scores 14–20) sometimes mild burn, tans uniformly (golden honey or olive)Type IV (scores 21–27) burns minimally, always tans well (moderate brown)Type V (scores 28–34) very rarely burns, tans very easily (dark brown)Type VI (scores 35–36) never burns (deeply pigmented dark brown to darkest brown)
Any observed skin hypersensitivity?

HotColdSharpSoftNone
Any observed contra-indications or skin conditions?
Colour discussed
Shape discussed
I certify that I was recommended to undergo a patch test, and that the risks involved should I choose not to go ahead with a patch test before the procedure have been explained to me.

I have had the opportunity to ask questions and have been provided with relevant information regarding the patch test and the treatment procedure. The information was explained to me to my satisfaction, and understanding.

I understand that I must notify the clinic should any adverse reactions occur Post treatment. However, in the event of medical anaphylaxis or a medical emergency that I must call the emergency services.

I understand that, in the case of an adverse reaction to my skin, I shall not hold close aesthetics no the clinician responsible for this adverse reaction.
Patch test confirmation*

I wish to undergo a patch testI do not wish to undergo a patch test. I take rough full responsibility and all the risk involved should any adverse reaction happen during or after the treatment.
Date*

MonthDayYear
Date
Signature*

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Full Name*

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PMU Consultation & Patch Test Form

Section 1 - Patch Test

Section 2 - The Consultation