Chemical Consent Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Do you have or are you prone to any of the following? Check all that apply.

Are you on any medications or do you have any hormonal issues that could cause a reaction to any chemical service?

If yes/other please explain here:

Please read carefully the following:

Hair chemicals including but not limited to hair color, perms, relaxers, keratin treatments, and other chemicals that may be used during your service may have certain side effects such as redness, scabbing, bruising, scarring, swelling, tenderness, and hyperpigmentation.

I have read the above information and if I had any concerns I have addressed them with my stylist. I give permission to my stylist to perform the hair chemical procedure we have discussed and will not hold my stylist or Peony House Beauty liable for any negative side effects that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies and/or prescription drugs or products I am currently ingesting or topically using. I understand my stylist will take every precaution to minimize or eliminate negative reactions. I am willing to follow the recommendations for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post treatment care, I will consult my stylist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above information and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the stylist or Peony House Beaury responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed.

This agreement will remain in effect for this procedure, and all future procedures conducted by my professional or any other professional conducting business at Peony House Beauty.

I understand and agree that this is a beauty service and there will be no refunds.

For the purpose of documentation and advertisement/social media usage, I also consent to the taking of “before” and “after” photographs of my service.

Date

Signature