Doctor's Consent Form

SPMU Doctor's Consent Form
For the attention of Doctor*
Your patient has contacted me hoping to receiving a permanent cosmetic tattoo. The process involves implanting pigment into the dermal layer of the skin, where it remains for a number of years.

As your patient has indicated a medical condition during my pre-procedure consultation with them, I ask that you consider the possible implications of the procedure and give your consent to them receiving the procedure.

If you feel that the procedure would have no detrimental effect to the health of your patient, please complete the details below.
Doctors Name*
Surgery Name*
Surgery Address*
Additional Medical Notes:
I understand that patient's name*will receive a permanent cosmetic tattoo. I have considered my patient's medical condition and feel that this procedure will have no detrimental effect on their health.
Signed*

Clear
Date*

DayMonthYear
Date
Should be Empty:

SPMU Doctor's Consent Form