The Patch Test Form Template UK is offered in a variety of formats, including PDF, Word, and Google Docs, featuring editable and printable versions to suit your needs.
Patch Test Form Template UK Editable – PrintableSample
Patch Test Form Template UK 1. Client Information 2. Treatment Information 3. Patch Test Details 4. Test Area Information 5. Allergies and Medical History 6. Consent for Patch Test 7. Results of Patch Test 8. Follow-up Instructions 9. Declaration and Signatures
PDF
WORD
Examples
[Name of the Client]
[Client’s ID]
[Client’s Address]
[Client’s Phone]
[Client’s Email]
[Name of the Service Provider]
[Provider’s ID]
[Provider’s Address]
[Provider’s Phone]
[Provider’s Email]
Date of Test: [Date]
Location: [Location of the Test]
The client should avoid the following before the test: [List of restrictions, e.g., sun exposure, medications, etc.].
1. Cleansing the Test Area
2. Application of Test Substance
3. Observation Time: [Time Period, e.g., 48 hours].
I, [Name of the Client], consent to the patch test and understand the procedure and potential reactions.
Signature: ____________________ Date: _______________
In case of an adverse reaction, please contact: [Emergency Contact Information].
[Name of the Client]
[Client’s ID]
[Client’s Address]
[Client’s Phone]
[Client’s Email]
[Name of the Service Provider]
[Provider’s ID]
[Provider’s Address]
[Provider’s Phone]
[Provider’s Email]
Date of Test: [Date]
Location: [Location of Test]
Clients should refrain from using the following: [List of products or activities to avoid prior to testing].
1. Skin Area Cleansing
2. Application of Patch
3. Monitoring Duration: [Duration of Monitoring, e.g., 48-72 hours].
I, [Name of the Client], hereby declare that I have been well informed about the patch test process and possible side effects.
Signature: ____________________ Date: _______________
Please contact the following: [Emergency Contact Information].
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