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Name
*
First Name
Last Name
Email
*
Contact Number
*
(###)
###
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Allergy Test
Medical Conditions or Allergies
*
Do you have any medical conditions or allergies, or are you taking any medication that we should be aware of?
Yes
No
If Yes, Please specify
Date of Colour Services
Allergic reactions in the past (temporary henna tattoo, make up, hair colouration)
Do you have a face rash, broken skin in the area of treatment or an irritated or damaged scalp?
*
Yes
No
Have you had any allergic reaction since your last colouration?
*
Yes
No
Have you disclosed all relevant information regarding any allergic reactions pertinent to the service here?
*
Yes
No
Terms and Conditions
By SUBMITTING THIS FORM, you agree to the following: 1) I give my permission to receive Hair Cutting and Colour services. 2) Where a Colour treatment has been completed I am fully aware that even with patch testing there is only a limited amount of exposure, and that a full treatment may have a different outcome, I will contact my stylist if any irritation, side effect or unwanted issue arrives that is a direct cause of any hair service that is carried out. 6) I fully understand the risks associated with hair coloring include, but are not limited to: • Scalp Bleach • Hair Coloring • Shampoo and Conditioners • Hair repair treatments • Toners I, therefore, release STACHE HAIR and the individual stylist from all liability concerning these injuries that may occur during the service as I am aware of the risks. 6) I understand the importance of informing my stylist of all medical conditions and medications I am taking, and to let the stylist know about any changes to these at any ongoing appointments. I understand that there may be additional risks based on my physical condition. 7) I understand that it is my responsibility to inform my stylist of any discomfort I may feel during the service so he/she may adjust the treatment accordingly. 8) I understand that I or the stylist may terminate the service at any time. 9)Photos of your service may be taken to aid in record keeping, and to be used with your permission on social media to help advertise the services available 10) I am aware that our appointments are subject to late cancellation due to guidlines in place with CV19 regulations. 11) I have been given a chance to ask questions about the service and my questions have been answered.
I confirm that I've read and understood the Terms and Conditions
Yes
No
STYLIST TO COMPLETE
Applied product (brand, shade, batch code and mixing ratio)Text Area 1
Condition of the scalp and hair
Date & result of the Allergy Alert Test
Recognising and responding to allergic reactions
Thank you!