Disclaimer - The goal of this treatment program is to help assist and accelerate natural hair growth. Under certain medical scalp disorder conditions, this treatment program should not be performed.
I affirm that I have stated my known medical conditions, and answered all questions correctly. I understand that there shall be no liability to Rekindle Hair Restoration Solutions Hair Salon and/or the Certified Hair Loss Practitioner/ Hair Stylist performing the treatment should I fail to provide accurate information anytime during the six weeks or 12 weeks of this treatment program. I understand that this consultation form and treatment program is not a substitute for a medical examination, diagnosis, or treatment. I understand that Rekindle Hair Restoration Solutions Hair Salon and/or the Certified Hair Loss Practitioner/ Hair Stylist(s) are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that none of the information stated in the course of this consultation should be construed as such.
I understand that the information herein is for evaluation purposes and to aid in giving a customized treatment for the absolute best result and is completely confidential.
By signing this consultation form, I understand and agree to the information contained within.