Head Spa Intake Form
Please complete this form to help us provide you with a safe and personalized head spa experience.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Appointment Date and Time
*
Have you received a head spa or scalp treatment before?
*
Yes
No
What are your main scalp or hair concerns? (Select all that apply)
*
Dry scalp
Oily scalp
Dandruff/flaking
Hair loss/thinning
Itching/irritation
Other
Please list any allergies or sensitivities (including to oils, fragrances, or products):
Please indicate if you have any of the following health conditions:
*
Skin/scalp infections
Recent head injury or surgery
Pregnancy
Heart condition
None of the above
Other
List any medications you are currently taking:
What hair or scalp products do you use regularly?
Emergency Contact Name and Phone Number
*
Submit Intake Form
Should be Empty: