Doctors Consent form Document 4

Doctors Consent Form – Document 4

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.

I am a fully qualified practitioner trained to the standards laid down by the Society of Permanent Cosmetic Professionals.

As my client has indicated a medical condition during a 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 the procedure wold have no detrimental effect to the health of your patient, please complete the details below

Doctor’s name…………………………………………………………………………………

Surgery name………………………………………………………………………………….

Address…………………………………………………………………………………………

I understand that (patients name) …………………………………………………… is to

Receive a cosmetic tattoo.  I have considered my patients medical condition and feel that this procedure will have no detrimental effect to his/her heath

Signed…………………………………………Date………………………………………….