Hair Spa Protein Mask Consent Form
Please complete this form to provide your consent and health information before receiving a hair spa protein mask treatment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Have you previously received a protein mask or similar hair treatment?
*
Yes
No
Do you have any known allergies or sensitivities (especially to hair products or ingredients such as keratin, wheat, soy, or nuts)?
*
No known allergies/sensitivities
Keratin
Wheat
Soy
Nuts
Other
Are you currently experiencing any scalp conditions or irritations?
*
No
Yes (please specify below)
If you answered 'Yes' to the previous question, please describe your scalp condition or irritation.
Are you currently pregnant, breastfeeding, or under medical treatment for any health conditions?
*
No
Yes (please specify below)
If you answered 'Yes' to the previous question, please provide details.
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature (Please sign below to confirm your consent)
*
Submit Consent
Submit Consent
Should be Empty: