Client Intake Form

Please fill out this required form to help us customize your scalp treatment experience.

Do not proceed with booking if you have any of the following contraindications (Specific health condition, symptom, or situation that makes a head spa treatment unsafe or otherwise inadvisable for you.

First Name

Last Name

Email Address

Phone Number

Emergency Contact

Emergency Contact Phone Number

Health History & Medications

Please list any medical conditions, allergies, or medications that may affect your treatment (e.g., skin conditions, pregnancy, recent surgeries).

Please explain any conditions:

Please explain any allergies:

How long have you experienced these concerns?

Have you experienced unusual hair loss recently?

Yes

No

Other:

What shampoo and conditioner do you currently use?

Photography Consent

I consent to before-and-after scalp photographs for treatment comparison. (No Face)

I consent to the use of my photos for educational and marketing purposes.

I do not consent to photography.

I understand that head spa treatments are designed to promote relaxation and improve scalp wellness but are not intended to diagnose, treat, or cure medical conditions.

I agree to inform my therapist immediately if I experience discomfort during my treatment.

I understand results vary from person to person and that multiple treatments and home care may be recommended.

I understand that providing complete and truthful health information is my responsibility. I understand that failure to disclose relevant medical conditions, medications ,or other health information may place my health at risk. I authorize the spa to refuse or discontinue treatment if it is determined that it is unsafe to proceed. I understand that I may forfeit my appointment and any applicable payments.

I have read and understand all spa policies and procedures.

Signature

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