Client Consent Form

First Name

Last Name

Date of Birth

Select an Address

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

Initials

I understand that the responsibility for the care and maintenance of the hairpiece is solely mine and I do not hold Replique Grooming Pty Ltd responsible for the care of the hairpiece, nor is Replique Grooming 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 Replique Grooming Pty Ltd agreeing to supply and fit the hairpiece I agree to release and forever discharge Replique Grooming 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.

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