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Gill East HAIR Medical and consent form
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Email
*
Your email
First name
*
Your answer
Last name
*
Your answer
Date of birth
MM
/
DD
/
YYYY
Address
*
Your answer
Postcode
*
Your answer
Mobile phone
*
Your answer
Are you aware of any previous reactions or allergies to hair colour, lightener or styling products?
Yes
No
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Do you, or have you suffered from sensitive skin on or around the scalp?
Yes
No
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Do you suffer from Eczema or Psoriasis on the scalp?
Yes
No
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Are you currently registered with any medical professional for any health issues, surgery, physio, or any other medical treatment?
Yes
No
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If yes, please provide details
Your answer
Do you currently take any regular medication?
Yes
No
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If yes, please provide details
Your answer
Do you, or have you suffered from any episodes of fainting, convulsions or blackouts?
Yes
No
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Do you suffer from epilepsy?
Yes
No
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Is there anything you would like to make me aware of that will better protect you, (and Gill) during your treatment
Yes
No
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If yes please provide details
Your answer
If yes please provide details
Your answer
I hearby authorise Gill East a fully trained and certified hair stylist to complete my treatment
I accept responsibility for the colour/finished look of the hair, as agreed during my consultation. I have completed a patch test prior to my treatment. (results below
I understand that a maintenance procedure is required to retain the completed look, and I am aware that I will be charged addtional fees for further work.
I understand that with any service certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks. I confirm that I completed the above to the best of my knowledge and the answers I have given are correct. I have not withheld any information.
I give my full consent for both before and after photos to be used for portfolio building and advertising
Please read carefully as this will be emailed to you and no response is considered your agreement.
If you do not agree to the above, please respond to the email or send an email to
gill@gilleast.com
stating what you do not agree to.
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