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Brow Patch Test Release Form

Let us do this part
Today's Date:
Thu Jul 17 2025 05:36
Practitioner:*
This patch test will cover you, and me in case of a reaction to the product used. It is YOUR responsibility to tell me immediately if you have any kind of reaction to your patch test area - or if you have reacted to a patch test in the past.
Please read and answer
Y
N
Have you had a reaction to any test patch previously?*
Details:
 
Y
N
Do you have any allergies or skin conditions that may affect this treatment?*
Details:
 
Y
N
I agree that if I react to this test patch I will inform Violets immediately*
Y
N
Have you anything Covid related to declare?*
Details:
 
Thank you.

By submitting this form, you are agreeing that you have given us accurate information to the best of your knowledge.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Name:*
Address:
Postcode:
Date of birth:*
Phone #:*
Email:*
Signature:*