Hair Color Patch Test Disclaimer Form
We require a patch test be performed 48 hours prior to any color/tint service(s). Please note that a negative patch test does not guarantee you will not have an adverse reaction to color/tint.
Please read the following information carefully:
Receiving any hair color service can, in some individuals, cause an allergic reaction.
This reaction can occur at any time even if I have received this service on previous occasions.
A negative skin patch test does not guarantee that a reaction will not occur.
These risks have been explained to me and if I have any concerns, I will seek medical advice prior to any color service.
Hair dye allergy symptoms include:
Stinging or burning sensation on the scalp, face, or neck
Blisters or welts
Itching or swelling of the scalp and face
Swollen eyelids, lips, hands, or feet
An angry, red rash anywhere on the body
Occasionally, a hair dye allergy will cause anaphylaxis to occur. This rare reaction is a medical emergency and can be fatal.
Symptoms of anaphylaxis may include:
Skin reactions such as stinging, burning, swelling, and rashes Swelling of the throat and tongue
If you experience any of the above symptoms please seek medical advice immediately.
Tap or click on the signature area above to sign.
I have read and understood the information provided to me in this form.
If you have tested positive for COVID-19, or have any symptoms of COVID-19 (see below) please do not attend your appointment. Please contact us as soon as you know you will be unable to attend so we can reschedule.
- a high temperature or shivering (chills) – a high temperature means you feel hot to touch on your chest or back (you do not need to measure your temperature)
- a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours
- a loss or change to your sense of smell or taste
- shortness of breath
- feeling tired or exhausted
- an aching body
- a headache
- a sore throat
- a blocked or runny nose
- loss of appetite
- feeling sick or being sick