Patch Test Consent & Client Authorization Form

Client Information

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Appointment Date

Month

Day

Year

Service History

Allergies & Previous Reactions

Please choose all that apply.

I have known allergies or sensitives

I have experienced previous reactions to brow or skin treatments

None of the above

Patch Test Consent

Please select one:

I consent to receiving an in-person patch test prior to my brow service

I decline the patch test and wish to proceed without one

Patch Test Acknowledgement

Required if you consent to patch test

I acknowledge that a patch test will be performed in-person prior to my brow service.

I understand that brow treatment products may cause allergic reactions or skin sensitivity, including redness, itching, swelling, irritation, or discomfort.

I understand that a patch test is intended to help identify potential reactions but does not guarantee that an allergic reaction will not occur.

I agree to notify my esthetician immediately if i experience any discomfort or reaction during or after the patch test or service.

Patch Test Decline & Waiver

Required if client DECLINES patch test

I acknowledge that I have been advised to receive a patch test prior to my brow service.

I voluntarily choose to decline the patch test.

I understand that declining the patch test increase my risk of experiencing an allergic reaction, irritation, redness, swelling, blistering, or discomfort.

I accept full responsibility for my decision to decline the patch test.

I release JSymone Collections, its licensed esthetician, from any liability related to adverse reactions or side effects that may occur as a result of proceeding without a patch test.

Client Consent

I confirm that all information provided is accurate and complete to the best pf my knowledge

I consent to receiving brow services performed by licensed esthetician at JSymone Collections.

I understand that individual results may vary and that adherence to aftercare instructions is required

Signature

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