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Get Printable Patch Test Disclaimer Form

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 Signature Date I WAIVE THE PATCH TEST DATE PHOTOGRAPHER S MODEL RELEASE 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 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. 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 Signature Date I WAIVE THE PATCH TEST DATE PHOTOGRAPHER S MODEL RELEASE 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 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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