New Client Intake Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Age* This field is required.
16-30
31-45
46-60
61+
4
Have you ever experienced hair loss?* This field is required.
YESNO
5
Have you ever been diagnosed with a scalp disorder?* This field is required.
YESNO
6
Check all that apply* This field is required.
Alopecia
Cancer/Chemotherapy
Dandruff
Dermatitis
Eczema
Fungal Condition
Hair Loss
Immune Disorders/Lupus
Cherry Angiomas
Psoriasis
Sensitive Skin
Moles
Other
7
Have you had or are you currently having any radiation treatments?* This field is required.
YESNO
8
Please tell me more. You can not receive the Ultimate Scalp Facial while undergoing radiation treatments.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
9
Any known allergies, including shellfish?* This field is required.
YESNO
10
Please list your known allergies* This field is required.
11
Are you taking medication that could affect the treatment (blood thinners, acutane, retinol, tretinoin, etc.)?* This field is required.
YESNO
12
Have you ever had a reaction to chemicals on your skin or scalp?* This field is required.
YESNO
13
Do you have any medical, heart conditions, or are you pregnant?* This field is required.
YESNO
14
Have you ever had Covid 19? If so did you experience hair loss?* This field is required.
YESNO
15
Do you understand when working with your scalp there can be possible irritations that can arise?* This field is required.
YESNO
16
What hair products are you currently using?* This field is required.
17
Will you have lash extensions during your Ultimate Scalp Facial appointment?* This field is required.
YESNO
18
Will you have hair extensions during your Ultimate Scalp Facial appointment?* This field is required.
YESNO
19
You must remove all hair extensions in order to receive the full Ultimate Scalp Facial. If extensions are not removed, your Ultimate Scalp Facial will be limited to Scope only and will be the same rate as the Ultimate Scalp Facial if not notifided before 72 hours.
20
Would you be interested in a 30 Day Refresher appointment?* This field is required.
YESNO
21
Would you be interested in a subscription treatment plan?* This field is required.
YESNO
22
How did you hear about Dawn Ambrose Scalp Facial?* This field is required.
Website
Referral
Instagram
Other
23
Who referred you, so we can thank you!* This field is required.
24
Due to limited space and the nature of the services provided, appointments are designed to ensure a calm and focused environment. For this reason, we kindly ask that you do not bring additional visitors or children with you to your appointment. Thank you for your understanding.* This field is required.
I agree to the policy regarding visitors and children.
25
Acknowledgment of Holistic Approach I understand that scalp health is a holistic process. Dawn Ambrose is not a doctor and cannot diagnose, treat, or prescribe medication. Her services provide a natural, holistic approach to improving scalp health and increasing hair density. I acknowledge that I should consult my doctor if I have any medical concerns. * This field is required.
I agree and acknowledge this holistic approach.
26
Thank you for filling out this New Client Intake Form! When you hit submit, you will be redirected to book your first appointment. Please select Dawn Scalp Facial under Professional and The Ultimate Scalp Facial. See you soon!* This field is required.
I agree to the cancellation policy and made Dawn aware of any issues that may render my service.
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