To plan your Liss Protocol, please fill out this form carefully.

Your answers will help us personalize the treatment to achieve the best results while maintaining the health of your hair.

Phone *

What are your expectations for this hair straightening treatment? *

If other, please specify:

_________

Have you ever had any chemical hair straightening treatments? *

If other, please specify:

If yes, how long ago?

_________

Have you ever had a keratin treatment or “blowout”? *

If yes, how long ago?

_________

Have you ever had highlights or hair bleaching? *

If yes, how long ago?

Have you noticed hair loss? *

Do you experience scalp itching? *

Do you have flaking on your scalp? *

How often do you wash your hair? *

How often do you use heat styling tools? *

Which tools do you use? *

If other, please specify:

Health History

Have you had any surgery in the past six months? *

If yes, please explain:

_________

Have you had COVID-19 in the past six months? *

If yes, when?

_________

Do you have diabetes? *

_________

Do you take any psychiatric medications? *

If other, please specify:

_________

Do you have any known allergies to hair products or chemicals? *

If yes, please list them:

For Re.Alise Staff Use Only

Natural Hair Type:

Texture:

Hair Condition:

Hair Condition - Other

Resistance:

Scalp Condition:

Recommended Protocol (by Re.Alise Specialist):

Specialist’s Name:

Terms and Disclaimer

I confirm that all information provided is true and accurate. I understand that omitting or providing incorrect information may compromise the results and the health of my hair.

I acknowledge and accept that this treatment may involve risks, including but not limited to: dryness, breakage, hair loss, scalp irritation, allergic reactions, or unexpected results depending on the history and condition of my hair.

I understand that results vary from person to person and that Re.Alise does not guarantee a specific outcome. I accept full responsibility for following the post-treatment care instructions. Failure to do so may affect the results and cause damage, for which Re.Alise will not be held liable.

I acknowledge that Re.Alise reserves the right to refuse or discontinue the service if it is determined that the procedure poses a health risk or is incompatible with the condition of my hair.

I release Re.Alise, its owners, staff, and service providers from any liability for adverse reactions or unsatisfactory results, except in cases of proven negligence.

I acknowledge that toned or colored hair may fade by up to two shades.

Free Touch-Up Policy (Liss Protocol only)

I understand that Re.Alise offers a free touch-up if waves reappear after the Liss Protocol. To request this service, I must contact Re.Alise within 7 days. The touch-up must be scheduled and completed within 15 days, both counted from the date of my signature. I understand that this policy is subject to professional evaluation by Re.Alise, limited to correction of the affected areas, and is valid only once per service. Eligibility requires compliance with post-treatment care instructions and the absence of new chemical processes or excessive heat use between the original procedure and the touch-up. This benefit is non-transferable, has no cash value, and is subject to availability.

Do you authorize the use of photos or videos of your treatment for promotional purposes? *

Yes

Today's Date *

Client’s Signature *

Clear