Perm, Relaxer & Keratin Treatment Consent Form

This consent form is required before any texture-altering chemical service — perming, chemical relaxing, or keratin / smoothing treatment. These services use strong reducing agents, hydroxides, or aldehyde-based smoothers that can permanently change the structure of your hair. Please read and complete every section carefully.

Section 1 — Client & Appointment

Full name:

Date of birth:

Appointment date: Appointment time:

Stylist / technician performing the service:

Section 2 — Service Requested

Select the specific service you are receiving today:

Traditional cold perm (thioglycolate-based curl)

Digital / hot perm

Sodium / lithium hydroxide relaxer ("lye" relaxer)

Calcium / guanidine hydroxide relaxer ("no-lye" relaxer)

Japanese / thermal straightening

Keratin smoothing treatment (formaldehyde-releasing)

Formaldehyde-free smoothing treatment

Product / brand being used (filled by stylist):

Desired result (e.g. loose waves, bone-straight, softer curl pattern):

Section 3 — Strand Test & Chemical History

A strand test is strongly recommended when combining chemical services or when hair has been previously processed. Mixing incompatible chemicals (e.g. hydroxide relaxer over a thioglycolate perm) can cause severe breakage.

Have you had any of the following chemical services in the last 12 months? Select all that apply:

Perm (thio-based)

Relaxer (hydroxide-based)

Keratin / smoothing treatment

Bleach / highlights

Permanent box-dye colour

None of the above

Date of most recent chemical service (if known):

Strand test performed today?

Yes — strand passed (no excessive breakage or gumminess)

Yes — strand showed concerning results; service adjusted or declined

No — client has waived strand test (see acknowledgement below)

Section 4 — Health & Safety Disclosure

Certain conditions can affect both the safety and the outcome of chemical services. Please tick everything that applies:

Cuts, abrasions, or inflammation on the scalp

Asthma or respiratory sensitivity (important for keratin / formaldehyde products)

Pregnant or breastfeeding (I have been advised to check with my doctor regarding formaldehyde exposure)

Currently on prescription medication that may affect hair or scalp

Known allergy to ammonium thioglycolate, hydroxides, formaldehyde, or glyoxylic acid

Hair shows signs of excessive breakage, elasticity loss, or chemical damage

None of the above apply

Any additional medical or hair-condition notes:

Section 5 — Risks Acknowledgement

Please tick each statement to confirm you have read and understood it:

I understand that texture-altering services break and re-form disulfide bonds and that some changes to my hair will be permanent until new hair grows in.

I understand that mixing chemical service types (e.g. relaxer with perm, or keratin over recently bleached hair) increases the risk of breakage and that my stylist may decline the service for my safety.

I understand that keratin smoothing products may release formaldehyde fumes during processing and that I should avoid inhaling steam/vapour where possible.

I understand that results such as final curl pattern, wave intensity, or degree of straightening can vary based on my hair type, porosity, and previous history.

I understand I must follow all aftercare instructions, including a mandatory neutralising period of no washing, tying up, clipping, or wetting the hair for the duration advised by my stylist.

I have disclosed all chemical service history and health information truthfully. I understand withholding information may result in poor outcomes that are not the salon’s responsibility.

Section 6 — Aftercare Window

First permitted wash date (filled by stylist):

Recommended at-home products:

Section 7 — Signature

If you have any concerns within the first 7 days after your service — such as unusual scalp irritation, excessive breakage, or your hair feeling "gummy" when wet — please contact the salon immediately so we can help.

Authorized representative — printed name:

Signed date:

Signer — printed name:

Signed date: