Full Name *

Data Of Birth *

Phone *

Email *

Instagram

Address

Address *

City *

State *

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

Your answers will help us customize the treatment to achieve the best results while keeping your hair healthy.

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 highlights or colored your hair? *

If yes, how long ago?

Have you noticed hair loss? *

Do you experience scalp itching? *

Do you experience scalp flaking? *

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

Are you currently taking any weight loss medication? (e.g., Mounjaro, Ozempic, etc.) *

Are you pregnant? *

If so, how long?

_________

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:

Terms and Disclaimer

I confirm that all information I have provided is accurate and truthful. I understand that omitting or misrepresenting information may compromise my results and hair health.

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

I understand that results vary by individual and that Re.Alise does not guarantee a specific outcome. I accept full responsibility for following the aftercare instructions provided. Failure to comply may affect 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 determines that the procedure presents a health risk or incompatibility with my hair condition.

I release and hold harmless Re.Alise, its owners, employees, and contractors from any liability for adverse reactions or unsatisfactory results, except in cases of proven negligence.

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

Complimentary Touch-Up Policy (Liss Protocol only).

I understand that Re.Alise offers a complimentary 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 timeframes counted from the date of my signature.

I understand this policy is subject to the professional assessment of Re.Alise, limited to correcting the affected areas, and is one-time per service.

Eligibility requires proper aftercare and no new chemical processes or excessive heat use between the original service and the touch-up.

This benefit is non-transferable, has no cash value, and is subject to availability.

This agreement shall be governed by the laws of the State of Florida.

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

Yes

Today's Date *

Client’s Signature *

Clear

Thank you so much!

For Re.Alise Staff Use Only

Tipo natural do cabelo:

Textura:

Condição do cabelo:

Condição do cabelo - Outros

Resistência:

Condição do couro cabeludo:

Protocolo recomendado (por especialista Re.Alise):

Nome do especialista: