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ALOHA HAIR REPLACEMENT CENTER

Welcome to the Aloha HAIR REPLACEMENT CENTER operated on-site by Aviella Aloha Stylist to the Stars. Please read the Service Agreement and complete the Client Profile Form below before your scheduled appointment. Note that no service will be performed without an electronic record of this form. When you are finished please 

click here to complete the Covid-19 Questionaire required by the State of Hawaii and Maui County. Mahalo for choosing AHRC.

ALOHA HAIR REPLACEMENT CENTER

Client Profile & Service Agreement

NAME*

EMAIL ADDRESS*

PHONE

OCCUPATION

BIRTH DATE

STATUS

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IN CASE OF AN EMERGENCY WHO SHOULD WE CONTACT?

HOW AND WHERE WOULD YOU PREFER WE CONTACT YOU?

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GENERAL INFORMATION

What type of hair replacement are you interested in discussing? (Please check all that apply)

How old were you when you first noticed hair loss?

Please detail hair loss in other members of your family.

Have you ever been treated for hair and or scalp issues?

Are you presently taking any medications/

What other hair replacement alternatives or options have you considered?

What activities ot hobbies do you participate in currently. (Please check all that apply)

Please indicate which areas of your hair loss affects you (check all that apply)

What is your main goal?

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If you have been advised by other professionals why have you chosen us?

Do you need someone (other than yourself) to assist in the decision to correct your hair loss problem?

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Are you able financially at this time to do something about your hair loss?

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Are you generally in good health?

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Are you currently under a doctor's care?

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Have you had prior hair transplants?

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Check any of the following that you currently or have ever had.

Have you ever had any types of bleeding disorders?

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Do cuts on your skin heal normally?

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Do you have any tendency towards keloids?

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Have you ever had allergic reactions to anethesia?

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Have you had any allergic response or adverse reactions to substances put on your skin?

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Do you take large amounts of aspirin?

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Have you had any allergic response or adverse reactions to any drugs or medications?

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List and describe any drugs or medications you are taking / prescribed to you.

Please describe any other concerns you may have or pertinent information we should know about you?

This information is accurate and I have fully answered all of the above questions honestly.

SERVICE AGREEMENT

STATE OF HAWAII, COUNTY OF MAUI


THIS AGREEMENT MADE AND ENTERED INTO THIS DAY, BY AND BETWEEN ALOHA HAIR REPLACEMENT CENTER, LLC(HEREINAFTER CALLED THE "CENTER") AND THE CUSTOMER NAMED ON THE FORM (HEREINAFTER CALLED "CLIENT").


WITNESSETH


THAT WEREAS THE CLIENT HAS ELECTED TO HAVE THE CENTER PREPARE AND PLACE A HAIRPIECE, AND THE CENTER HAS AGREED TO PERFORM SUCH PROCEDURE FOR THE CUSTOMER, AND THE PARTIES WHICH TO AGREE IN WRITING TO THE AMOUNT, TIME AND PLACE OF PAYMENT. 


NOW THEREFORE IN CONSIDERATION OF THE PREMISES AND THE SERVICE TO BE PROVIDED BY THE CENTER, AND ITS PERFORMANCE OF THE HAIR SERVICE PROCEDURE, THE CUSTOMER AGREES AS FOLLOWS: 


TYPE OF SERVICE / UNIT TO BE PROVIDED BY CLIENT

 1. THE CUSTOMER WILL PAY THE SUM OF $ 95.00/HR FOR THE PREPARATION AND PLACEMENT OF THE HAIRPIECE. 


 2. THIS IS A NON-REFUNDABLE DEPOSIT . THE CLIENT WILL PAY THE TOTAL AMOUNT BEFORE THE MOLD OF HIS OR HER HEAD IS PREPARED BY THE CENTER.


 3. THE CLIENT WILL PAY THE BALANCE UPON PLACEMENT OF THE COMPLETE HAIRPIECE IN CASH.


I ACKNOWLEDGE THAT I HAVE BEEN FULLY ADVISED CONCERNING THE DANGERS OF CHEMICAL PROCESSING OF THE HAIR. I FURTHER UNDERSTAND THAT THE GUARANTEES I AM RECEIVING ARE FOR WORK PERFORMANCE AS LONG AS I FOLLOW INSTRUCTIONS GIVEN TO ME ON THE PROPER MAINTENANCE OF MY CHEMICAL HAIRSTYLE. i UNDERSTAND THAT PERMANENT WAVES, PERMANENT, SEMI PERMANENT OR TEMPORARY COLORS, ADHESIVES AND RELAXERS ARE ALL CONSIDERED CHEMICALS.


I UNDERSTAND THAT THE SERVICES RENDERED BY THE CENTER ARE AT MY OWN RISK AND I RELEASE ALOHA HAIR REPLACEMENT CENTER, LLC AND THE PERSONS PERFORMING THE CHEMICAL PROCESS SERVICE FROM ALL LIABILITY INVOLVING THESE SERVICES.


IN WITNESS WHEREOF, THE CLIENT HAS EXECUTED THIS AGREEMENT, THIS DAY AND YEAR FIRST WRITTEN.


CUSTOMER SIGNATURE______________________________

DATE__________ 


ALOHA...WELCOME TO MAUI, HAWAII

To Check Availability: 808-357-3504

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