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: _________________________________________________

Address: ______________________________________________________

_____________________________________________________________

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.

Signed:__________________________________________ Date:_________

 

 

 

 

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.

Yes No
Stroke
Structural heart problems
Diabetes
Angina or previous Myocardial Infarction

(Heart Attack)

Chronic kidney disease
Ischemic heart disease (IHD)

or Myocardial Ischaemia

 

Name                         ________________________________________

 

Signature      ________________________________________

 

Date                ________________________________________

 

A Doctors Consent is needed if you answer YES to any of the above questions.