Patch Test Consent & Record Form

🔬 [Business Name] 👤 Therapist: [Your Name] 📅 Date: [Date]
Important: A patch test is required at least 24–48 hours before treatment for any service involving tinting, lash lift chemicals, colour, bleach, or other chemical products. If a reaction occurs, do not proceed with the treatment under any circumstances. Always err on the side of caution.

Section A — Client Details (completed by client)

Client full name
Date of birth
Phone number
Email address

Section B — Treatment Requiring Patch Test (completed by therapist)

Please tick the treatment(s) for which this patch test is being carried out:

Eyebrow tint
Eyelash tint
Lash lift / perming solution
Eyebrow lamination
Henna brow
Chemical hair removal / depilatory
Chemical peel product
Other:
Product name(s) and brand used for patch test
Patch test site (e.g. inside elbow / behind ear / inner wrist)
Date and time of patch test application
Therapist name & initials

Section C — Pre-Test Client Health Check (completed by client)

Please answer the following questions honestly. Your answers help us keep you safe.

I have had a patch test with this therapist before and had no reaction (if yes, date: )
I have previously had a reaction to a tint, chemical, or similar product
I have a known allergy to PPD (para-phenylenediamine) or similar dye components
I have sensitive skin or known skin allergies
I am currently taking medication that may affect skin sensitivity
I have had recent cosmetic treatments (e.g. fillers, Botox, peels) in or near the test area
Any additional relevant information?

Section D — Patch Test Instructions for Client

Please read and follow these instructions carefully after your patch test:
  • Leave the patch test product on for the full duration specified by your therapist (usually 24–48 hours)
  • Do not wet, rub, or cover the test area
  • Monitor the test site for any signs of reaction: redness, swelling, itching, burning, blistering, or rash
  • If you experience any reaction at all, wash the area with cool water immediately and contact your therapist. Do not proceed with the treatment
  • If you experience breathing difficulties, swelling of the face/throat, or severe reaction, call 999 immediately
  • Return or contact your therapist at least 24 hours after the patch test to confirm your result before booking

Minimum waiting period before treatment: [24 hours / 48 hours — circle as applicable]

Section E — Patch Test Result (completed by therapist at result check)

Result Assessment

Date and time of result check
NO REACTION — Clear to treat

No redness, swelling, itching or other reaction observed at test site. Treatment may proceed.

REACTION OBSERVED — Do NOT proceed

Reaction noted. Treatment must not be carried out. Refer client to GP if reaction is significant.

Description of reaction (if applicable)
Action taken / advice given
Therapist name & initials (result check)

Section F — Client Confirmation of Result

Before treatment proceeds, the client must confirm they have reviewed the patch test site and observed the result.

I confirm I have checked the patch test site and observed no reaction
I understand that if I experience any delayed reaction before my appointment, I must contact my therapist immediately and not proceed with treatment
I understand that a reaction after a previously clear patch test is possible and I consent to proceeding at my own risk

Client Confirmation

Client signature (confirming result checked & consent to treat)

Date of signature

Therapist

[Your Name] — confirming patch test administered and result recorded

Date