Patch Test Form

Patch Test Form
Name

First NameLast Name
Date of Appointment

MonthDayYear
Date
What Treatment have you booked for:
1. Are you under 16 years of age?*

YesNo
2. Have you ever had an allergic reaction to lash tint, Lash Glue, Lash lift products or Brow lamination products ?*

YesNo
3. Have you got a sensitive, irritated or damage to your Face/Eyes?*

YesNo
*Sorry, for your own protection if the answer to questions 1, 2 or 3 is yes we can’t provide you with this service. We do not treat under 16 years. We recommend that you seek advice from a GP or dermatologist, who will need to provide written consent for us to provide you with this treatment in future.
4. Have you had any type of skin tattoo, including temporary “black henna” tattoo or permanent make-up, since your last treatment or in the last 6 months?

YesNo
5. Have you had an allergic reaction to any products since your last treatment?

YesNo
6. Are you currently taking medication for allergies?

YesNo
7. Is it more than 6 months since your last treatment OR 12 months since you last had an allergy test?

YesNo
If you answered No to question 7 what date was your last treatment of patch test? (provide the nearest date known)

MonthDayYear
Date
If You have answered Yes to questions 4 -7 then you will need to book in for a patch test 24 - 48 hours before your treatment.
Even if a patch test is provided with no reaction, there is still a chance that a reaction can still occur after/during treatment. We recommend that you seek immediate medical advice in this instance.

I verify that i undertand all risks and will not hold the therapist or Beauty at the Lodge responsible for any reactions, damage or injury for any of the above listed treatments.
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