Client Consent Form

First name

Last name

Date of Birth

Select an Address

Phone

Do you have any of the following: Discolouration, swelling or bumps on scalp. A history of skin based allergies. Chronic skin diseases. Contact allergies.If Yes please state more details below.

Yes

If you answered yes to any question, please elaborate

I understand that the responsibility for the care and maintenance of the hairpiece is solely mine and I do not hold The Company responsible for the care of the hairpiece, nor is The Company responsible for any quality issues with the hair piece or bonding, or any issues related to my body’s reaction to the hair piece, hair piece adhesive or any other products used in bonding the hair piece to the scalp. In consideration of the Company agreeing to supply and fit the hairpiece I agree to release and forever discharge the Company and all of its employees, consultants and contractors from all demands, claims, actions, suits, costs and expenses now or later arising in relation to the hair piece, hair piece adhesive or any other products used in the bonding of the hair piece to the scalp

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!