Hair Protein Infusion Consent Form
Please review and complete this form to provide your informed consent for the hair protein infusion treatment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you experienced any allergic reactions to hair treatments or protein-based products in the past?
*
No, I have not experienced any allergic reactions.
Yes, I have experienced allergic reactions.
Not sure
Please list any medical conditions, medications, or allergies we should be aware of before your treatment.
Signature (Please sign below to confirm your consent)
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: