Patch Test

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Patch Test

Email *

Full Name: *

Date of Birth:
*

Address, City, State, & Zip Code

Phone Number:

Treatment : *

Patch Test Day:
*

YYYY

Patch Test Site : *

Pigment Product:

Hanafy

Permablend

Numbing Product:

Emla 5%

Have you ever had an allergic or adverse reaction to any of the following? *

Tattoo or PMU pigments

Numbing / anaesthetic products

Skincare products

Nickel / metals

Other

No known allergies

If YES please provide details: *

Are you currently pregnant or breastfeeding? *

YES

Are you currently taking any medication or prescription treatment? *

Do you have any known medical condition that may affect healing, bleeding, skin sensitivity or your suitability for PMU?

YES

Clear selection

If YES please provide details:

Do you have diabetes or any condition that may affect wound healing? *

YES

If YES please provide details

Do you have any active skin condition, infection, cold sore, rash, irritation, swelling, wound or inflammation in or around the treatment area? *

YES

If YES please provide details

Patch Test

Did you experience any reaction at the test site?

No Reaction

Redness

Itching

Swelling

Burning / Stinging

Rash

Other

Required

If you experienced a reaction, please provide details:

Date result was checked:

YYYY

Final Patch Test Result:

PASS – No concerning reaction observed

REACTION – Treatment must not proceed until appropriately assessed

FURTHER ASSESSMENT REQUIRED

CLIENT DECLARATION & CONSENT

Please tick each box to confirm:

I confirm that the information I have provided is true and complete to the best of my knowledge.

I have informed the practitioner of any known allergies, medical conditions, medication and skin conditions that may affect my treatment.

I understand that a patch test is an indicator of possible sensitivity and cannot guarantee that an allergic or adverse reaction will not occur.

I understand that PMU involves the implantation of pigment into the skin and carries potential risks including irritation, allergic reaction, infection, scarring, pigment changes and unsatisfactory results.

I understand that the practitioner may refuse or postpone treatment if they believe it is not safe or appropriate to proceed.

I understand that I should follow the aftercare instructions provided by the practitioner.

I agree to contact the practitioner if I experience any unusual or concerning reaction following the treatment.

I have had the opportunity to ask questions and have received sufficient information about the procedure before giving my consent.

Client Confirmation: *

I confirm that I have read, understood and agree to the above.

Required

A copy of your responses will be emailed to the address you provided.

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