Patch Test Form PDF Details

Ensuring informed consent is a critical aspect of any cosmetic or medical procedure, and the Patch Test Consent Form epitomizes this principle. It serves as a vital document for those considering undergoing a patch test, typically used for identifying potential allergic reactions to pigments applied during cosmetic procedures. This form documents the client's acknowledgment of having received the patch test, while also releasing the practitioner, in this case, Michelle Keith, R.N., from liability for any allergies or reactions that may occur from the pigments used. Furthermore, it alerts clients to the fact that reactions could develop at any time post-procedure and that sun exposure might exacerbate these reactions. In addition to the consent portion, the form includes a waiver option for those choosing to forgo the patch test. Also embedded within the document is a Photographer’s Model Release section, giving Michelle Keith, R.N., the permission to use the client's before and after photos under specified conditions. This comprehensive form not only ensures that the client is well-informed but also protects the practitioner legally, marking an essential step in the preparatory process for permanent makeup services.

QuestionAnswer
Form NamePatch Test Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespersonal product form for patch testig, tint patch test consent form, brow lamination patch test form, patch test form template

Form Preview Example

PATCH TEST CONSENT FORM

I have received a patch test on the date below. The patch test has been received and it releases Michelle Keith, R.N. from any liability related to any allergies or other reaction to applied pigments. I have been informed that reactions can occur at any time in the future. Sun exposure can also cause a reaction with the pigments (colors).

Client:____________________________________

Location: Top/Mid Scalp

Color:___________________________________

________________________________________ Date:_____________________

Signature

I WAIVE THE PATCH TEST: _____________________________DATE:_________________

Signature

PHOTOGRAPHER’S MODEL RELEASE

I, ______________________________________, assign Michelle Keith, R.N. permission

to use my before and after pictures in one of the areas below:

(Check all that apply)

I want my picture in my medical file only

My pictures may be viewed in the photo album by others

_____________________________________

________________________

Signature

Date

Permanent Makeup by Michelle

HealthPlex

3400 W. Tecumseh Road, Suite 204, Norman, OK 73072

Office: (405) 310-6727 or Cell: (405) 919-2628

Michellekeithmakeup.com

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