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Permanent Makeup <br /> Patch Test Consent Form <br /> Appointment date Appointment time <br /> l <br /> FULL NAME <br /> D.O.B. AGE 0 PHONE# <br /> ADDRESS <br /> Patch testing involves placing small amount of the substance against the skin and axing <br /> them in place for 48-72 hours. The testing site is then monitored for local reaction. Potential <br /> adverse events include rash at the site, infection, or delayed skin reaction. There is a possibility <br /> of an allergic reaction to the substance. A patch test is advisable however it does not ensure a <br /> client will not have an allergic reaction. <br /> Do you have any allergies?Please state: <br /> I have been offered the option of patch test, I understand the decision to decline a <br /> —7--T.77 <br /> patch test may result in reactions and/or being refused treatment. <br /> I can confirm the reactions, sensitivities and risks of the treatment have been fully <br /> explained to me. <br /> I accept the risks, reactions and sensitivities that can arise from having this <br /> (iaitiols) <br /> treatment and have disclosed all allergies to my therapist.As a result,I will not hold <br /> the therapist liable in anyway for my reactions, allergies, sensitivities and injures <br /> that might happen as a result of this treatment. <br /> . ..... ....._.... <br /> ......•...............eli'eriiria"m'e'........_......_......•. ,hereby consent and authorise t'1iera'TsiTiaTon name <br /> to perform this treatment. <br /> Date: <br /> CLIENT NAME(PRINTED) <br /> CLIENT SIGNATURE <br />