Chemical Release Form

Chemical Release Form
Name
First NameLast Name
Phone Number
Area CodePhone Number
Email
example@example.com
Due to AVEDA’s new formulation in their chemical services (hair color, perms, ect.), Moda Bella Salon and Spa recommends all clients receiving such services to receive a forty-eight hour patch test prior to services.
I am aware and understand that receiving any chemical service can, in some individuals, cause an allergic reaction. I fully understand that this reaction can occur at any time even if I have received this service on previous occasions. I further understand that it is Moda Bella Salon and Spa’s, policy to perform a skin patch test forty-eight hours prior to all chemical services. I also understand that a negative skin patch test does not mean that a reaction will not still occur. I understand these risks and if I have any concerns I will seek medical advice prior to any chemical service.
Patch Test
(I understand that byaccepting a patch test, I must reschedule my current appointment for 48 hoursafter my patch test was received)
Further, I grant Moda Bella Salon and Spa, its employees and representatives, permission to chemical services on my hair and not hold them responsible for any and all adverse health reactions from this service.
By signing this form, I assume all risk of injury and harm resulting from the treatment activity specified herein and I agree to release, defend, indemnify, and forever discharge the Salon from all liabilities, claims, damages, costs, and expenses, or any action due to loss, damage, injury, or death that might incur resulting from the chemical treatment.
Signature of Client
Clear
Date Signed
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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