Patch Test Consent Form

Patch Test Consent Form
Patch Testing is a procedure for testing a customer's skin for any allergic reaction from a substance that is going to be used for the procedure that he or she desires to undergo. It involves placing a few drops or a small amount of the substance on the skin, leaving it for around 48 hours for observation for potential reaction or effects which may include rashes, infection, or any skin irritation.
A topical cream will be applied before and during your procedure to numb your eyebrow area and keep pain to a minimum during your appointment. This cream may cause some allergic reaction and thus, it is necessary that a patch test is to be made.
Patch Testing is one of the classic methods for checking with a client if he or she has any allergic reaction to any of the creams or skin applications that shall be used on him/her. This way, we can safely proceed with the procedure if no allergic reaction happens after 48 hours. Although a patch test is made, however, this is not a guarantee that the client will not have any further allergic reaction.
The Patch Test
A topical cream will be applied before and during your procedure for purposely numbing your eyebrow area. This is for the purpose of minimizing the pain that one would experience in the procedure.
The cream contains glycerin, ethanol, distilled water, iron oxide, isopropyl alcohol, titanium dioxide, and nickel. It also has the following ingredients: carbopol, lecithin, lidocaine, vitamin E, and propylene glycol. Thus, if you know that you have any allergic reaction to any of the ingredients, please notify us.
I hereby declare that I was recommended to undergo a patch test. It was explained to me the risks involved should I choose not to go with the patch test prior the procedure. I have had the opportunity to ask questions as well as relevant information regarding the patch test was explained to me to my satisfaction. I understand that I must notify the technician in case any adverse effects happen after the treatment in order to receive proper instructions on the next measures to take.
I understand that in the case of an adverse reaction to my skin, I shall not hold the clinic or my technician responsible.
Consent to Patch Test
I wish to undergo a patch test prior the treatment.I do not wish to undergo a patch test. I take full responsibility and all the risk involved should any adverse reaction happens during or after treatment.
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Phone Number
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Email*
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Clients Signature*
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Therapist Signature *
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