Doctor’s Consent Form
For The Attention of Doctor________________________________________
Dear Sir, your patient ___________________________________________ has contacted me with a view to receiving a cosmetic tattoo. The process involves implanting pigment into the dermal layer of the skin where it remains for a number of years.
As my client has indicated a medical condition during pre-procedure consultation it would be preferable that you consider the implications and give your consent to him / her receiving the procedure.
If you feel that the procedure would have no detrimental effect to the health of your patient, please complete the details below.
Doctor’s Name: _________________________________________________
Surgery Name: _________________________________________________
I understand that (patient’s name) __________________________________
is to receive a cosmetic tattoo. I have considered my patient’s medical condition and feel that this procedure will have no detrimental effect to his/ her health.
Confirmation Of High Blood Pressure
I, ____________________________________ acknowledge that I am regularly visiting my
doctor regarding my high blood pressure and this is controlled by medication.
I do not have any of the following medical health conditions relating to high blood pressure.
|Structural heart problems|
|Angina or previous Myocardial Infarction
|Chronic kidney disease|
|Ischemic heart disease (IHD)
or Myocardial Ischaemia
A Doctors Consent is needed if you answer YES to any of the above questions.