Allergy Patch Test Waiver Form
Use this form to review basic patient information, screen for allergy-related concerns, and record waiver acknowledgment before an allergy patch test.
Patient Information
Full Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Allergy and Medical Screening
Main reason for patch test / suspected allergen concern
*
Known allergies or prior reactions to adhesives, tapes, topical medications, or patch testing materials
*
Current medications and topical products used on the test area
*
Skin conditions or recent irritation at the intended test site
*
Waiver and Acknowledgment
Patient Signature
*
Submit
Submit
Should be Empty: