New Client Intake and Consent Form

Today's Date*

Date

Name*

First NameLast Name

Date of Birth (15% off during birthday week)*

Date

How did you hear about us?*

Facebook/InstagramOnline SearchReferralOther

If referred, by who?

Have you seen a Dermatologist for scalp issues in the past year?*

YesNo

If yes, list the reason for visit:

Do you have or have ever had any of the following?*

If other, please explain:

Any known allergies*

LatexFragrances/Essential OilsNoneOther

Have you ever had an adverse reaction after using any hair care product?*

YesNo

If yes, please check all that apply:

If yes, which products or brands?

Please list any other allergies or sensitivities:

Are you pregnant or post partum?

YesNo

What do you consider your scalp/hair type?*

What hair care products do you currently use?*

In the last 18 months, have you had any of the following?*

What services are you interested in?*

How often would you prefer to come in for maintenance appointments?*

Are there any specific concerns at this time regarding your hair?*

Essential oil preference*

Silent Appointment

YesNo

Music Preference

By SUBMITTING AND SIGNING THIS FORM, I acknowledge, consent and agree to the following:

I give my permission to receive hair care services.

I understand that the stylist does not diagnose illnesses or injuries, or prescribe medications.

I have clearance from my physician to receive hair care services.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that this treatment is strictly an elective cosmetic procedure and no medical claims have been expressed or implied.

I understand the importance of informing my stylist of all medical conditions and medications I am taking, and to let the stylist know about any changes to these.

I understand that it is my responsibility to inform my stylist of any discomfort I may feel during the session so he/she may adjust accordingly.

I understand that I or the stylist may terminate the session at any time.

I have been given a chance to ask questions about the session and my questions have been answered.

I have read and accept Studio 512's cancellation policy.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments.

Signature*

New Client Intake Form

Customize Your Experience