Patch Test Consent/Waiver Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Do you have any existing allergies? *

Please list: *

Are you currently (or possibly may be) pregnant or breastfeeding? *

Do you have any medical conditions? *

Please list: *

Have you previously experienced a reaction to dye / tint / treatment / product ? *

Please specify: *

Consent

While allergies to treatments are unusual, it is always possible to have a reaction in regards to any new treatment we undertake. Please read the following statements carefully.

Please tick each statement to show your understanding and agreement: *

I confirm that I have disclosed all relevant information to my therapist I confirm I have had all potential side effects/reactions explained to me in regards to this treatment

Please select: *

I am having my patch test today and I understand that even though only a small area is treated there is a possibility there may be a reaction within this area and I am choosing to go ahead with this treatment taking all benefits and potential side effects into consideration I am consenting to having my treatment today without having a patch test. I understand why they are recommended but I have decided that I knowingly and voluntarily waive this skin patch test for today. I acknowledge that a patch test is available at any time as per my request

Client Name, Signature and Date: *

Tap or click on the signature above to sign

Appointment Guidance

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.

COVID-19 Symptoms:

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
diarrhoea
feeling sick or being sick

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